Claim Revenue Optimization - Ontario

Transcription

1 Claim Revenue Optimization - Ontario Pharmacy Technology Solutions January, 2015

2 Modify a Prescription The Claim Revenue Optimization (CRO) is an integrated function in PharmaClik Rx that will help enhance your pharmacy s margin with minor changes to the way you fill prescriptions When a prescription is filled CRO determines if there are potential errors in the claim that may result in the loss of money If there is a potential error the claim will be returned as a Pre-Edit window message It is required that the user take action through the Pre-Edit window, which will provide clear instructions on which appropriate modifications need to be made to the claim It is possible to override, pend or modify a prescription through the Pre-Edit response window 1. Fill a prescription until the Pre-Edit window appears. 2. Press or click the Print button. 3. Press or click Go To Rx. 4. Modify the prescription as required. 5. Fill the prescription. 6. Update the DIN as necessary. McKesson Canada, All rights reserved. The Information contained in this document is proprietary to McKesson Canada. 2

3 Pend an Edit Using the Pend function allows action on a claim to take place at a later time. 1. Fill a prescription until the Pre-Edit window appears. 2. Press or click the Print button. 3. Press or click the Pend button. The prescription will be stored on the Workbench in the Pending tab with a status of INCOMPLETE 4. When ready to modify the prescription, highlight it in the Pending tab then press or click the Detail button. 5. Modify the prescription as required. 6. Fill the prescription. 7. Update the DIN as necessary. Override an Edit If a Pre-Edit messages can be skipped if you choose not to respond to the recommendation. 1. Fill a prescription until the Pre-Edit window appears. 2. Press or click the Print button. 3. Press or click the Skip Edit button. The prescription will process as usual and will appear on your bi-weekly report To manually override an edit, enter a * in the Special Auth # field for the first online third party in the bill code McKesson Canada, All rights reserved. The Information contained in this document is proprietary to McKesson Canada. 3

4 Response Codes One or more of the following response codes may be returned when submitting claims online Follow the steps to resolve the issue and to prevent these codes from reappearing on future claims *D Cost-to-Operator Pricing Edit (PRIVATE 3 rd Party) The current list price of the drug is higher than what you are billing. 1. Verify the drug cost with your supplier. 2. In Rx Detail of the prescription go into the Drug folder and update the price in the Inventory tab. 3. Fill the prescription. *F Replacement Cost Pricing Edit (ODB) ODB have recently accepted a MI intervention code which means no interchangeable is available for this medication Submitting the claim at acquisition cost with no markup may result in a higher profit margin Use same steps as identified below *G Replacement Cost Pricing Edit *G Replacement Cost Pricing Edit (ODB) Claim may be eligible for an MI intervention code Submitting the claim at acquisition cost with no markup will result in a higher profit margin 1. Press or click the Revert button. 2. If the Acq Cost prompt appears, press or click the Yes button. a) If the prompt does not appear, open the Drug folder and enter the lowest generic price in the Prov $ field. b) Press or click OK to return to Rx Detail. c) Press or click Yes to the Acq Cost prompt. 3. Fill the prescription. McKesson Canada, All rights reserved. The Information contained in this document is proprietary to McKesson Canada. 4

5 Response Codes (cont d) *L Government Formulary Pricing Edit (ODB & PRIVATE 3 rd Party) The prescription is being submitted to the drug plan at less than the government formulary price 1. Verify the drug cost with your supplier. 2. In Rx Detail of the prescription go into the Drug folder and update the price in the Inventory tab. 3. Fill the prescription. 4. Verify that your pricing and variable pricing rules are set up correctly in PharmaClik Rx. *M Government Formulary Pricing Edit (ODB) The claim is incorrectly being submitted with an MI intervention code The price should be the provincial price plus an 8% markup 1. Press or click the Third Party tab in Rx Detail. 2. Remove the MI intervention code. 3. Fill the prescription. McKesson Canada, All rights reserved. The Information contained in this document is proprietary to McKesson Canada. 5

6 Response Codes (cont d) *U DIN Deduced Edit (ODB & Private 3 rd Party) The claim is eligible for a higher reimbursement if the correct pseudo DIN is submitted to the third party You must change the Pseudo DIN being submitted in order to receive the correct payment 1. Press or click the Third Party tab within Rx Detail. 2. Enter the correct Pseudo DIN in the Alternative DIN field. 3. From the Main tab in Rx Detail, press or click the Drug Folder. 4. Press or click the TP Rules button. 5. Add the correct Pseudo DIN into the appropriate third party s PIN field. 6. Press or click OK to return to Rx Detail. 7. Fill the prescription. McKesson Canada, All rights reserved. The Information contained in this document is proprietary to McKesson Canada. 6

7 Response Codes (cont d) *X Minimum Total Cost (ODB & Private 3 rd Party) The Minimum Total Cost edit helps protect your profits by validating the submitted cost on the prescription against the expected minimum total cost (MTC) for the pack size being dispensed. Validates that the correct quantity was submitted for the prescription. If quantity being submitted is correct, ensure T.P. Rules in the drug file is submitting the correct T.P. Quantity 1. Press or click the Main tab in Rx Detail. 2. Ensure the correct quantity has been submitted in the Qty field. If the correct quantity was submitted, ensure correct setup of the T.P. Qty in the TP Rules button within the Drug folder 3. From the Main tab in Rx Detail, press or click the Drug Folder. 4. Press or click the TP Rules button. 5. Ensure the setup of the TP Qty being submitted is the correct quantity. 6. Press or click OK to return to the Drug folder. 7. Press or click OK to return to Rx Detail. 8. Press or click the Fill button. McKesson Canada, All rights reserved. The Information contained in this document is proprietary to McKesson Canada. 7

8 Response Codes- Bi-weekly Excel Reports ONLY *N & *O Payer Accepted Cost Pricing Edit (ODB & PRIVATE 3 rd Party) The third party has accepted more than what you are submitting for this claim This response code will only appear on your bi-weekly Excel report 1. Verify the drug cost with your supplier and then update the Drug folder in PharmaClik Rx. 2. Verify that your pricing and variable pricing rules are set up correctly in PharmaClik Rx. 3. Rebill the prescription with the new drug cost. McKesson Canada, All rights reserved. The Information contained in this document is proprietary to McKesson Canada. 8

9 Post Edit Response Codes Post Edit response codes will appear on your bi-weekly reports and can be corrected afterwards. C = Captured An edit code of C on your bi-weekly reports could be for 2 different reasons: 1. This claim qualified for a reject but the opportunity value was below $1.00. To correct, update DIN and rebill, if possible 2. Payer accepted amount. To correct, analyze markup in Pricing tabs RO = Reject Override An edit code of RO can happen for two different reasons: 1. Skip Edit The Skip Edit button was selected at the time of filling, therefore it was recorded as a missed value Skip Edits with the same prescription number will appear with 2 lines on the bi-weekly report as R and RO in the Edit Action column Investigate why reject was skipped Rebill if appropriate 2. Batch Filled Rx s Prescriptions filled in a batch are automatically overridden by CRO Only appear as RO in the Edit Action column on weekly reports Rebill if appropriate R = Reject Claim was rejected by CRO and the edit screen was displayed This is considered a Realized Value Claim already corrected at the time of filling McKesson Canada, All rights reserved. The Information contained in this document is proprietary to McKesson Canada. 9