Table of Contents
I. Introduction
II. Outpatient
Pharmacy V. 7.0
A. Tricare 3rd party claim
submissions
B. Reject notification screen
C. Reject Worklist and
View/Process
1. Display of non-DUR/RTS
rejects
2. Processing of Tricare
Rejections
D. In Progress 3rd
Party Claims
E. Inactive ECME Tricare
F. Reject Processing Screen
Default Answer Modifications
G. Nutritional Supplement
H. Flagged Pending Orders
I. Introduction
This patch has enhancements which extend the
capabilities of the Veterans Health Information Systems and Technology
Architecture (VistA )
electronic pharmacy (ePharmacy) billing system.
This patch is being released along with
PSS*1*139 and IB*2*405. These patches
can be installed in any order but the full functionality for Nutritional
Supplement additions contained within these patches will not be available until
all 3 patches are installed.
For Tricare functionality, previously
nationally released patches PSO*7*287, PSX*2*66, IB*2*383, and BPS*1*6
comprised the ePharmacy Tricare dormant
release. Patches PSS*1*139, PSO*7*303,
and IB*2*405 comprise the ePharmacy Tricare active
release.
Tricare
functionality described in this document will become active when IB*2*405 patch
is installed and a Tricare Payer Sheet is subsequently defined for the
site. For sites that do not bill
Tricare, the software will remain dormant.
For sites who bill Tricare prescriptions, the ePharmacy Implementation
Team will notify them when they should activate ePharmacy Tricare billing.
(This page included for two-sided copying.)
Tricare
Functionality:
The software will be activated when a Tricare
payer sheet is linked. See Integrated
Billing documentation for information concerning payer sheet linkage and
contact your billing administrator before activating a Tricare payer sheet.
- Prescriptions where the patient is Tricare eligible will be submitted to ECME for third party insurance processing in the same manner as all other insurance types. Patients with dual eligibility insurance is not addressed with this release of Tricare.
- When a Tricare prescription has a third party rejection, the same reject notification screen will be displayed to the user as is currently done for the Veteran eligibility.
- The Third Party Payer Rejects - Worklist [PSO REJECTS WORKLIST] option and the Third Party Payer Rejects - View/Process [PSO REJECTS VIEW/PROCESS] option has been modified to process and display Tricare third party rejections.
- If ECME's status on the claim remains in an "In Progress" state past the processing time out during finish of the prescription, Tricare prescriptions will not be filled and must be discontinued.
- If the pharmacy is active for ePharmacy processing, but the insurance plan is not linked or not active, Tricare prescriptions will be allowed to be filled normally. The phrase "Inactive ECME Tricare" will be displayed during Finish of the prescription.
Miscellaneous
Functionality Modifications:
This functionality is active for all sites:
- Modifications to change the default answer of (I)gnore on the Reject Processing Screen to (Q)uit, which automatically sends the claim rejection information to the Pharmacy Reject Worklist for these actions: new orders, copies, edits that create new orders, and renewals.
- Software was added to handle the new "N” for Nutritional Supplement DEA special handling code added in patch PSS*1*139. This new "N" code will be treated the same as supply items and investigational drugs in Outpatient Pharmacy.
- For the ePharmacy Medication Profile (VIEW ONLY) [PSO PMP] option, flagged pending orders will be noted on the medication profile screen by highlighting the sequence number shown on the left side of the screen. Note that the "Flagged by..." information shown once the prescription is selected is already present with the PSO*7*225 release.
A. Tricare 3rd party claim submissions
Prescriptions where the patient is Tricare
eligible will be submitted to ECME for third party insurance processing in the
same manner as all other insurance types.
Tricare dual eligibility will not be addressed in this release. Tricare eligibility is determined by Integrated
Billing (IB). An indicator is returned to Outpatient Pharmacy PRESCRIPTION file
(#52) and REFILL multiple (#52.1), to be stored in the new BILLING ELIGIBILITY
INDICATOR field (#85). Because this is a
set of codes field, the internal value will be T, V or C. These values will be displayed
respectively to the user as TRICARE, VETERAN, or CHAMPVA. Note: CHAMPVA submissions will not be addressed in
this patch. Prescriptions with a 'VETERAN'
eligibility flag are currently processed through ECME.
B. Reject notification screen
When ePharmacy is active for the site and
upon finish of a prescription, a third party claim submission is made to
ECME. If the third party payer rejects
the claim, a reject notification screen is displayed to the user for reject
codes of Refill-too-soon (79) and DUR (88).
With this patch, the same reject notification screen will be displayed
for Tricare prescriptions that have a third party claim rejection. Tricare rejections will be stored in the same
manner as DUR (88) and RTS (79)
prescription rejects except for the following:
The following exceptions will apply for
Tricare prescriptions:
- Rejected
Tricare claims will be denoted with “TRICARE” during submission to ECME
phase and within the subsequent reject notification screen. Also, the reject codes will be displayed
in both places. The following
example shows a prescription being submitted to ECME and this process
occurs directly following the “Is this correct? YES//” prompt during
finish:
TRICARE Prescription
101110 submitted to ECME for claim generation.
Claim Status:
IN PROGRESS-Waiting to
start
IN PROGRESS-Building the
claim
IN PROGRESS-Transmitting
IN PROGRESS-Processing
response
E REJECTED
79 - Refill Too Soon
14 - M/I Eligibility Clarification Code
*** REJECT RECEIVED FOR TRICARE PATIENT ***
-------------------------------------------------------------------------
Division : ALBANY
Patient
: OPTRICARE,ONE(666-55-4789) Sex:
M DOB: OCT 18,1963(44)
Rx/Drug
: 101110/0 - NAPROXEN 250MG S.T.
ECME#: 0112303
Reject(s): REFILL TOO SOON (79), 14 - M/I Eligibility Clarification
Code (14).
Received on MAR 03,
2008@14:40:57.
Insurance
: TRICARE
Contact:
Group Name
: TRICARE PRIME Group
Number: 123123
Cardholder ID: SI9844532
-------------------------------------------------------------------------
Select one of the following:
O (O)VERRIDE - RESUBMIT WITH OVERRIDE
CODES
D (D)iscontinue - DO NOT FILL
PRESCRIPTION
Q (Q)UIT - SEND TO WORKLIST (REQUIRES
INTERVENTION)
(O)verride,(D)iscontinue,(Q)uit: Q//
- Where DUR or RTS are one of the reject codes, the user will be able to select from (D)iscontinue the prescription, submit (O)verride codes, or (Q)uit which sends the rejection to the Third Party Payer Rejects - Worklist. A tricare rejection may not be (I)gnored.
- For prescription rejections that have non-DUR/RTS rejects, the user will be able to select from (D)iscontinue the prescription or (Q)uit which sends it to the Third Party Payer Rejects - Worklist. Tricare prescriptions with these type rejects cannot be filled until the rejection is resolved. Example:
TRICARE Prescription
101113 submitted to ECME for claim generation.
Claim Status:
IN PROGRESS-Waiting to
start
IN PROGRESS-Building the
claim
IN PROGRESS-Building the
HL7 packet
IN PROGRESS-Transmitting
E REJECTED
07 - M/I Cardholder ID Number
14 - M/I Eligibility Clarification Code
*** REJECT RECEIVED FOR TRICARE
PATIENT ***
-------------------------------------------------------------------------
Division : ALBANY
Patient
: OPTRICARE,ONE(666-55-4789) Sex:
M DOB: OCT 18,1963(44)
Rx/Drug
: 101113/0 - SIMETHICONE 40MG TAB
ECME#: 0112306
Reject(s): M/I Eligibility Clarification
Code (14), M/I Cardholder ID
Number (07). Received on MAR 03, 2008@14:43:42.
Insurance
: TRICARE
Contact:
Group Name
: TRICARE PRIME Group
Number: 123123
Cardholder ID: SI9844532
-------------------------------------------------------------------------
Select one of the following:
D (D)iscontinue - DO NOT FILL
PRESCRIPTION
Q (Q)UIT - SEND TO WORKLIST (REQUIRES
INTERVENTION)
(D)iscontinue,(Q)uit: Q//
For non-billable Tricare prescriptions, an
abbreviated version of the reject notification screen will be displayed. Because the prescription is non-billable, the
insurance and ECME information that's currently provided for DUR/RTS rejects
will not be displayed (i.e. insurance, group name, group #, ECME #, contact, cardholder
ID). In this case, the prescription is discontinued.
Is this correct? YES// ...
*** TRICARE -
NON-BILLABLE ***
-------------------------------------------------------------------------
Division : ALBANY
Patient :
OPTRICARE,ONE(666-55-4789) Sex: M DOB: OCT 18,1963(44)
Rx/Drug : 102058/0 - ABSORBABLE
GELATIN S
Date/Time: AUG 27, 2008@16:49:46
Reason : Drug not billable.
-------------------------------------------------------------------------
This is a non-billable Tricare
prescription. It cannot be filled or
sent
to the reject worklist. It must be discontinued.
Press <RETURN> to continue...
Nature of Order: SERVICE CORRECTION// S
Requesting PROVIDER: OPHARM OPPHARM,ONE OO
- Labels will not print for discontinued Tricare prescriptions., and reprint label will not be allowed for Tricare rejected prescriptions.
Select Rx (Prescriptions)
Option: REPrint an Outpatient Rx Label
Reprint Prescription
Label: 101113 SIMETHICONE 40MG
TAB
Number of Copies? : (1-99): 1//
Print adhesive portion of
label only? ? No// NO
Do you want to resend to
Dispensing System Device? No// NO
Comments: REPRINT
Rx # 101113 03/03/08
OPTRICARE,ONE #180
ONE MOUTH TWICE A DAY
SIMETHICONE 40MG TAB
OPPHARM,ONE OPPHARM,ONE
# of Refills: 3
Select LABEL DEVICE:
NULL Bit Bucket
No Label(s) printed.
Reprint Prescription
Label:
- Suspended prescriptions will remain on suspense when a reject occurs, when the Rx is non-billable, or when the third party claim remains in an 'IN PROGRESS' status in ECME. Labels will not print. Once the reject is resolved, the user may pull the Rx early from suspense or wait for the next scheduled Print from Suspense option runs at which time labels will print accordingly. This includes CMOP and local suspense.
TRICARE Prescription
101607 submitted to ECME for claim generation.
Claim Status:
IN PROGRESS-Building the
claim
IN PROGRESS-Transmitting
IN PROGRESS-Parsing
response
*** TRICARE - 'IN PROGRESS' ECME status ***
-------------------------------------------------------------------------
Division : ALBANY
Patient
: OPTRICARE,ONE(666-55-4789) Sex:
M DOB: OCT 18,1963(44)
Rx/Drug
: 101607/0 - ACETAZOLAMIDE 250MG
Date/Time: APR 20, 2008@20:11:17
Reason
: ECME Status is in an 'IN PROGRESS' state and cannot be filled
-------------------------------------------------------------------------
This prescription will be
suspended. After the third party claim
is resolved,
it may be printed or
pulled early from suspense.
Press <RETURN> to
continue...
- Rejected Tricare prescription may not have a partial fill ordered until the reject is resolved.
OP Medications (SUSPENDED) Apr 18, 2008@19:10:16 Page: 1 of
2
OPTRICARE,ONE
PID: 666-55-4789 Ht(cm):
_______ (______)
DOB: OCT 18,1963 (44) Wt(kg): _______
(______)
Rx #: 101526e
(1) *Orderable Item: ACETAZOLAMIDE PILL
(2)
Drug: ACETAZOLAMIDE 500MG SEQUELS
Verb: TAKE
(3)
*Dosage: 1 PILL
*Route: ORAL
*Schedule: BID
(4)Pat Instructions:
SIG: TAKE 1 PILL BY MOUTH
TWICE A DAY
(5)
Patient Status: OTHER FEDERAL
(6)
Issue Date: 04/18/08
(7) Fill Date: 04/19/08
Last Fill Date: 04/19/08 (Window)
Last Release Date:
(8) Lot #:
Expires: 04/19/09 MFG:
+
DC
Discontinue PR Partial RL Release
ED
Edit RF (Refill) RN Renew
Select Action: Next Screen// p Partial
OP Medications (SUSPENDED) Apr 18, 2008@19:10:16 Page: 1 of
2
OPTRICARE,ONE
PID: 666-55-4789 Ht(cm):
_______ (______)
DOB: OCT 18,1963 (44) Wt(kg): _______ (______)
Rx #: 101526e
(1) *Orderable Item: ACETAZOLAMIDE PILL
(2)
Drug: ACETAZOLAMIDE 500MG SEQUELS
Verb: TAKE
(3)
*Dosage: 1 PILL
*Route: ORAL
*Schedule: BID
(4)Pat Instructions:
SIG: TAKE 1 PILL BY MOUTH
TWICE A DAY
(5)
Patient Status: OTHER FEDERAL
(6)
Issue Date: 04/18/08
(7) Fill Date: 04/19/08
Last Fill Date: 04/19/08 (Window)
Last Release Date:
(8) Lot #:
Expires: 04/19/09 MFG:
+ Partial cannot be filled on
Tricare non-payable Rx
DC
Discontinue PR Partial RL Release
ED
Edit RF (Refill) RN Renew
Select Action: Next
Screen//
- When the Pull Early from Suspense [PSO PNDRX] option is used, Tricare prescriptions will be processed in the foreground and rejections will be displayed for user intervention.
Print a specific Rx # or
all Rx's for a patient: (S/A): SPECIFIC
RX
Select SUSPENDED Rx #:
101980
DANTROLENE 25MG CAP 08-14-08 OPTRICARE,ONE
Select one of the following:
M MAIL
W WINDOW
Select routing for Rx(s):
WINDOW//
METHOD OF PICK-UP:
Pull Rx(s) and delete
from suspense? Y// ES
TRICARE Prescription
101980 submitted to ECME for claim generation.
Claim Status:
IN PROGRESS-Waiting to
start
IN PROGRESS-Building the
claim
IN PROGRESS-Transmitting
E REJECTED
14 - M/I Eligibility Clarification Code
*** TRICARE - REJECT RECEIVED FROM
THIRD PARTY PAYER ***
-------------------------------------------------------------------------
Division : ALBANY
Patient
: OPTRICARE,ONE(666-55-4789) Sex:
M DOB: OCT 18,1963(44)
Rx/Drug
: 101980/0 - DANTROLENE 25MG CAP
ECME#: 0113204
Reject(s): M/I Eligibility Clarification
Code (14). Received on AUG 13,
2008@15:41:30.
Insurance
: TRICARE
Contact:
Group Name
: TRICARE PRIME Group
Number: 123123
Cardholder ID: SI9844532
-------------------------------------------------------------------------
Select one of the following:
D (D)iscontinue - DO NOT FILL
PRESCRIPTION
Q (Q)UIT - SEND TO WORKLIST (REQUIRES
INTERVENTION)
(D)iscontinue,(Q)uit:
Q// (Q)UIT - SEND TO WORKLIST (REQUIRES
INTERVENTION)
No Label(s) printed.
C. Reject Worklist and View/Process
The Third Party Payer Rejects - Worklist [PSO
REJECTS WORKLIST] and Third Party Payer Rejects - View/Process [PSO REJECTS
VIEW/PROCESS] options have been modified in the following manner:
1. Display of non-DUR/RTS rejects
- Non-DUR/RTS Tricare rejections will be segregated at the end of the displayed information. They will be denoted with a "TRICARE - Non-DUR/RTS" header. This header will remain regardless of whether the GI - Group by Insurance action is toggled on or off. The Tricare section will sort in the same manner as the main sort for non-Tricare prescriptions (i.e. by Rx, drug, patient, etc.).
Insurance
Rejects-Worklist Aug 13,
2008@16:04:05 Page: 1 of
1
Division : ALBANY
Selection : ALL
UNRESOLVED REJECTS
# Rx#
PATIENT(ID) [^] DRUG REASON
1 101238
ECMEIBTEST,ONE(5566)
MEDROXYPROGESTRONE 1 79 :REFILL TOO SO
Payer Message:
2 100739
ECMEPAT,TWO(8887)
BENZTROPINE 2MG TAB 79 :REFILL
TOO SO
Payer Message:
3 101960
OPTRICARE,ONE(4789)
ACETAZOLAMIDE 250MG 79 :REFILL
TOO SO
Payer Message:
TRICARE - Non-DUR/RTS
4 101980
OPTRICARE,ONE(4789)
DANTROLENE 25MG CAP 14 :M/I
Eligibili
Payer Message:
Select the entry # to view or ?? for
more actions
DR Sort by Drug RE
Sort by Reason RX Sort by Prescription
PA Sort by Patient RF
Screen Refresh GI Group by Insurance
Select: Quit//
- Tricare DUR/RTS rejects will be displayed with all other DUR/RTS rejects. See the boxed text in the example below. Sequence 4 and 6 are rejects for the same prescription. Also note that in the following example GI - Group by Insurance action is toggled OFF.
Insurance Rejects-Worklist Aug
13, 2008@16:10:22 Page: 1 of
1
Division : ALBANY
Selection : ALL UNRESOLVED REJECTS
# Rx# PATIENT(ID)
[^] DRUG REASON
1 101238 ECMEIBTEST,ONE(5566) MEDROXYPROGESTRONE 1 79 :REFILL TOO SO
Payer Message:
2 100739 ECMEPAT,TWO(8887) BENZTROPINE 2MG TAB 79 :REFILL TOO SO
Payer Message:
3 101960 OPTRICARE,ONE(4789) ACETAZOLAMIDE 250MG 79 :REFILL TOO SO
Payer Message:
4 101981 OPTRICARE,ONE(4789) ATENOLOL 100MG TAB 79 :REFILL TOO SO
Payer Message:
TRICARE - Non-DUR/RTS
5 101980 OPTRICARE,ONE(4789) DANTROLENE 25MG CAP 14 :M/I Eligibili
Payer Message:
6 101981 OPTRICARE,ONE(4789) ATENOLOL 100MG TAB 14 :M/I Eligibili
Payer Message:
Select the entry # to
view or ?? for more actions
DR Sort by Drug RE
Sort by Reason RX Sort by Prescription
PA Sort by Patient RF
Screen Refresh GI Group by Insurance
Select: Quit//
When GI - Group by Insurance action is
toggled ON, the header "TRICARE" will be displayed, and this
"TRICARE" section will sort alphabetically within RTS/DUR insurances. This Tricare section is separate from the
Non-DUR/RTS section that displays at the end of the listing.
Example with GI action toggled on:
Insurance
Rejects-Worklist Aug 13,
2008@16:12:46 Page: 1 of
1
Division : ALBANY
Selection : ALL
UNRESOLVED REJECTS GROUPED BY INSURANCE
# Rx#
PATIENT(ID) [^] DRUG REASON
BLUE CROSS BLUE SHIELD
1 100739
ECMEPAT,TWO(8887)
BENZTROPINE 2MG TAB 79 :REFILL
TOO SO
Payer Message:
TRICARE
2 101960
OPTRICARE,ONE(4789)
ACETAZOLAMIDE 250MG 79 :REFILL
TOO SO
Payer Message:
ZENITH ADMINISTATORS
2 101238
ECMEIBTEST,ONE(5566)
MEDROXYPROGESTRONE 1 79 :REFILL TOO SO
Payer Message:
4 101981
OPTRICARE,ONE(4789) ATENOLOL
100MG TAB 79 :REFILL TOO SO
Payer Message:
TRICARE - Non-DUR/RTS
5 101980
OPTRICARE,ONE(4789) DANTROLENE 25MG CAP 14 :M/I Eligibili
Payer Message:
6 101981
OPTRICARE,ONE(4789) ATENOLOL
100MG TAB 14 :M/I Eligibili
Payer Message:
Select the entry # to view or ?? for
more actions
DR Sort by Drug RE
Sort by Reason RX Sort by Prescription
PA Sort by Patient RF
Screen Refresh GI Group by Insurance
Select: Quit//
- The new TRI - Show/Hide Tricare toggle action has been added to the hidden menu on the Insurance Rejects screen. When toggled to Show, Tricare Non-DUR/RTS rejects will be automatically displayed at the end of the listing. Toggling the TRI action to Hide will remove them from the screen.
Example with Tricare rejects displayed:
Insurance
Rejects-Worklist Aug 13,
2008@16:04:05 Page: 1 of
1
Division : ALBANY
Selection : ALL
UNRESOLVED REJECTS
# Rx# PATIENT(ID)
[^] DRUG REASON
1 101238
ECMEIBTEST,ONE(5566)
MEDROXYPROGESTRONE 1 79 :REFILL TOO SO
Payer Message:
2 100739
ECMEPAT,TWO(8887)
BENZTROPINE 2MG TAB 79 :REFILL
TOO SO
Payer Message:
3 101960
OPTRICARE,ONE(4789)
ACETAZOLAMIDE 250MG 79 :REFILL
TOO SO
Payer Message:
TRICARE - Non-DUR/RTS
4 101980
OPTRICARE,ONE(4789)
DANTROLENE 25MG CAP 14 :M/I
Eligibili
Payer Message:
Select the entry # to view or ?? for
more actions
DR Sort by Drug RE
Sort by Reason RX Sort by Prescription
PA Sort by Patient RF
Screen Refresh GI Group by Insurance
Select: Quit// ??
The following actions are
also available:
TRI Show/Hide Tricare FS
First Screen PT Print List
+ Next Screen LS
Last Screen SL Search List
- Previous Screen GO
Go to Page ADPL Auto Display(On/Off)
UP Up a Line RD
DN Down a Line PS
Print Screen
Enter RETURN to continue
or '^' to exit:
Example of Tricare
rejects removed from display:
Insurance
Rejects-Worklist Aug 13, 2008@16:04:05 Page: 1 of
1
Division : ALBANY
Selection : ALL
UNRESOLVED REJECTS
# Rx#
PATIENT(ID) [^] DRUG REASON
1 101238
ECMEIBTEST,ONE(5566)
MEDROXYPROGESTRONE 1 79 :REFILL TOO SO
Payer Message:
2 100739
ECMEPAT,TWO(8887)
BENZTROPINE 2MG TAB 79 :REFILL
TOO SO
Payer Message:
3 101960
OPTRICARE,ONE(4789)
ACETAZOLAMIDE 250MG 79 :REFILL
TOO SO
Payer Message:
Select the entry # to view or ?? for
more actions
DR Sort by Drug RE
Sort by Reason RX Sort by Prescription
PA Sort by Patient RF
Screen Refresh GI Group by Insurance
Select: Quit// ??
The following actions are
also available:
TRI Show/Hide Tricare FS First Screen PT
Print List
+ Next Screen LS
Last Screen SL Search List
- Previous Screen GO
Go to Page ADPL Auto
Display(On/Off)
UP Up a Line RD
DN Down a Line PS
Print Screen
Enter RETURN to continue
or '^' to exit:
2. Processing of Tricare Rejections
·
The Reject Information screen has been modified
to display TRICARE in the header for the Reject Information section. For DUR/RTS Tricare rejects, the IGN - Ignore
Reject action will be shown but will not be selectable.
In the following example the user entered IGN
to ignore the RTS (79) reject. The
system displayed “INVALID: TRICARE rejected Rxs may not be ignored” on the
message bar because the reject is a Tricare refill-too-soon reject.
Reject
Information(UNRESOLVED)Aug 13, 2008@16:41:59 Page: 1 of
1
Division : ALBANY
Patient : OPTRICARE,ONE(666-55-4789) Sex: M DOB: OCT 18,1963(44)
Rx# : 101981/0 ECME#: 0113205 Fill Date: Aug 13, 2008
CMOP Drug: ATENOLOL 100MG
TAB NDC Code:
66993-0220-57
REJECT Information (TRICARE)
Date/Time : AUG 13, 2008@16:10:11
Reject(s) : Refill Too Soon (79)
Status : OPEN/UNRESOLVED - E REJECTED
OTHER REJECTS
14 - M/I Eligibility
Clarification Code
INSURANCE
Information
Insurance : TRICARE
Contact :
Group Name : TRICARE PRIME
Group Number : 123123
Cardholder ID : SI9844532
INVALID: TRICARE rejected Rxs
may not be ignored.
VW View Rx IGN Ignore Reject OVR Submit Override Codes
MP Medication Profile RES Resubmit Claim CSD Change Suspense Date
Select: Quit// IGN Ignore Reject
·
For Non-DUR/RTS Tricare rejects, the FIL - Fill
Rx action and the DC - Discontinue Rx action will be displayed. If the
prescription is payable, the user will be allowed to fill the prescription and
print the label. If not payable, a
message will be displayed stating the prescription must have a payable status
to be filled.
Example of Reject Information screen for
non-DUR/RTS reject:
Reject Information (TRICARE) Aug 13, 2008@16:39:14 Page: 1 of
1
Division : ALBANY
Patient : OPTRICARE,ONE(666-55-4789) Sex: M DOB: OCT 18,1963(44)
Rx# : 101980/0 ECME#: 0113204 Fill Date: Aug 14, 2008
Drug : DANTROLENE 25MG CAP NDC Code:
00149-0030-66
REJECT Information (TRICARE)
Date/Time : AUG 13, 2008@15:41:30
Reject(s) : M/I Eligibility Clarification Code
(14)
Status : OPEN/UNRESOLVED - E REJECTED
INSURANCE
Information
Insurance : TRICARE
Contact :
Group Name : TRICARE PRIME
Group Number : 123123
Cardholder ID : SI9844532
Enter ?? for more actions
VW View Rx FIL Fill Rx OVR Submit Override Codes
MP Medication Profile DC
Select Item(s): Quit//
·
The following is an example of a user selecting
to discontinue the prescription shown above.
The user selects DC at the Select Item prompt, and answers the normal
discontinue prompts. When the user exits
and re-enters the worklist, the discontinued prescription will be removed from
the listing.
Select Item(s): Quit//
DC Discontinue Rx
Nature of Order: SERVICE
CORRECTION// S
Requesting PROVIDER: OPPHARM,ONE OO
Claim has status E
REJECTED. Not reversed.
Reject Information
(TRICARE) Aug 13, 2008@16:53:40 Page: 1 of
1
Division : ALBANY
Patient : OPTRICARE,ONE(666-55-4789) Sex: M
DOB: OCT 18,1963(44)
# Rx#
PATIENT(ID) [^] DRUG REASON
CMOP Drug: ATENOLOL 100MG
TAB NDC Code:
66993-0220-57
REJECT Information
(TRICARE)
Date/Time : AUG 13, 2008@16:53:20
Reject(s) : M/I Cardholder ID Number (07)
Status : OPEN/UNRESOLVED - E REJECTED
INSURANCE
Information
Insurance : TRICARE
Contact :
Group Name : TRICARE PRIME
Group Number : 123123
Cardholder ID : SI9844532
NO ACTION TAKEN.
VW View Rx FIL Fill Rx OVR Submit Override Codes
MP Medication Profile DC
Select Item(s):
Quit// QUIT
PA Sort by Patient RF
Screen Refresh GI Group by Insurance
Insurance Rejects-Worklist Aug 13, 2008@16:53:52 Page: 1 of
1
Division : ALBANY
Selection : ALL
UNRESOLVED REJECTS
# Rx#
PATIENT(ID) [^] DRUG REASON
1 101238
ECMEIBTEST,ONE(5566)
MEDROXYPROGESTRONE 1 79 :REFILL TOO SO
Payer Message:
2 100739
ECMEPAT,TWO(8887)
BENZTROPINE 2MG TAB 79 :REFILL
TOO SO
Payer Message:
3 101960
OPTRICARE,ONE(4789)
ACETAZOLAMIDE 250MG 79 :REFILL
TOO SO
Payer Message:
TRICARE -
Non-DUR/RTS
4
101980 OPTRICARE,ONE(4789) DANTROLENE 25MG CAP 14 :M/I Eligibili
Payer Message:
5 101985
OPTRICARE,ONE(4789) ATENOLOL
100MG TAB 07 :M/I Cardholde
Payer Message:
Enter ?? for more actions
DR Sort by Drug RE
Sort by Reason RX Sort by Prescription
PA Sort by Patient RF
Screen Refresh GI Group by Insurance
Select: Quit// QUIT
# Rx#
PATIENT(ID) [^] DRUG REASON
MP
ePharmacy Medication Profile (View Only)
PF
ePharmacy Medication Profile Division Preferences
SP
ePharmacy Site Parameters
VP
Third Party Payer Rejects - View/Process
WL
Third Party Payer Rejects - Worklist
Select ePharmacy Menu
Option: Third Party Payer Rejects -
Worklist
You may select a single
or multiple DIVISIONS,
or enter ^ALL to select
all DIVISIONS.
DIVISION: ALBANY ISC//
500 ALBANY
ANOTHER ONE:
Please wait...
PA Sort by Patient RF
Screen Refresh GI Group by Insurance
Insurance
Rejects-Worklist Aug 13, 2008@16:54:57
Page: 1 of
1
Division : ALBANY
Selection : ALL
UNRESOLVED REJECTS
# Rx#
PATIENT(ID) [^] DRUG REASON
1 101238
ECMEIBTEST,ONE(5566)
MEDROXYPROGESTRONE 1 79 :REFILL TOO SO
Payer Message:
2 100739
ECMEPAT,TWO(8887)
BENZTROPINE 2MG TAB 79 :REFILL
TOO SO
Payer Message:
3 101960
OPTRICARE,ONE(4789)
ACETAZOLAMIDE 250MG 79 :REFILL
TOO SO
Payer Message:
TRICARE -
Non-DUR/RTS
4 101980
OPTRICARE,ONE(4789)
DANTROLENE 25MG CAP 14 :M/I
Eligibili
Payer Message:
Select the entry # to view or ?? for
more actions
DR Sort by Drug RE
Sort by Reason RX Sort by Prescription
PA Sort by Patient RF
Screen Refresh GI Group by Insurance
Select: Quit//
·
A person who resolves Tricare non-DUR/RTS
rejects is dependent upon the type of reject.
Dispense As Written(DAW) reject code 22 can be resolved by pharmacy
staff by editing the prescription and entering the appropriate DAW code which
would result in a claims resubmission.
Other insurance related rejects (i.e.
missing eligibility or cardholder ID number) would be resolved by the
Outpatient Pharmacy Electronic Claims Coordinator (OPECC). Once the rejection has been resolved, the Reject
Information screen under the pharmacy reject worklist will show the status of
the prescription as E PAYABLE. At this
point the user may select the FIL action which will prompt for label
print.
Reject Information
(TRICARE) Aug 27, 2008@17:16:27 Page: 1 of
1
Division : ALBANY
Patient : OPTRICARE,ONE(666-55-4789) Sex: M DOB: OCT 18,1963(44)
Rx# : 102059/0 ECME#: 0113288 Fill Date: Aug 27, 2008
Drug : IMIPRAMINE 25MG TAB NDC Code:
00779-0588-30
REJECT Information
(TRICARE)
Date/Time : AUG 27, 2008@17:15:08
Reject(s) : M/I Cardholder ID Number (07)
Status : OPEN/UNRESOLVED - E PAYABLE
INSURANCE
Information
Insurance : TRICARE
Contact :
Group Name : TRICARE PRIME
Group Number : 123123
Cardholder ID : SI9844532
Enter ?? for more actions
VW View Rx FIL Fill Rx OVR Submit Override Codes
MP Medication Profile DC
Select Item(s): Quit//
FIL Fill Rx
[Closing all rejections for
prescription 102059:
07 - ...OK]
Print Label? ? YES//
Select LABEL PRINTER:
HOME// UCX/TELNET Right Margin: 80//
·
For rejects that remain in suspense, the user
will be allowed to process the rejection as indicated above, however no labels
will be printed until the prescription is pulled early or printed from suspense. Upon resolving the reject, the user will be
notified of this information. CMOP
prescriptions will function in the same manner.
D. In Progress 3rd Party Claims
If ECME's status on the claim remains in an
"In Progress" state past the processing timeout during finish of the
prescription, Tricare prescriptions will not be allowed to be filled. Instead it will be placed on suspense until
the rejection is resolved. Below is an
example of this screen:
TRICARE Prescription 101607 submitted to ECME
for claim generation.
Claim Status:
IN PROGRESS-Building the claim
IN PROGRESS-Transmitting
IN PROGRESS-Parsing response
*** TRICARE - 'IN PROGRESS'
ECME status ***
-------------------------------------------------------------------------
Division : ALBANY
Patient :
OPTRICARE,ONE(666-55-4789) Sex: M DOB: OCT 18,1963(44)
Rx/Drug : 101607/0 -
ACETAZOLAMIDE 250MG
Date/Time: APR 20, 2008@20:11:17
Reason : ECME Status is in an
'IN PROGRESS' state and cannot be filled
-------------------------------------------------------------------------
This prescription will be suspended. After the third party claim is resolved,
it may be printed or pulled early from
suspense.
Press <RETURN> to continue...
E. Inactive ECME Tricare
If a pharmacy is active for ePharmacy
processing but an insurance plan is not linked or not active, Tricare
prescription will be allowed to be filled without third party claim submission. The phrase "Inactive ECME Tricare"
will be displayed during Finish and an ECME log entry will be added stating
such.
Example of message during finish:
Do you want to enter a Progress Note? No// NO
Rx #
102046 08/27/08
OPTRICARE,TEST #180
ONE MOUTH TWICE A DAY
DANTROLENE 25MG CAP
OPPROVIDER,ONE OPPHAR,ONE
# of Refills: 3
Is this correct? YES// ...
-Rx
101921 has been discontinued...
Inactive ECME Tricare
Example of
ECME Activity Log entry:
ECME Log:
#
Date/Time Rx Ref Initiator Of Activity
===============================================================================
1
8/27/08@11:07:45 ORIGINAL OPPHARM,ONE
Comments: TRICARE-Inactive ECME Tricare
F. Reject Processing Screen Default Answer Modifications
The default answer of (I)gnore on the Reject Processing
Screen will be changed to (Q)uit which automatically sends the claim rejection
information to the Pharmacy Reject Worklist.
This modification is for new orders, copies, edits that create new
orders, and renewal functions. All other
functions were addressed in nationally released patch PSO*7*281.
Original prescription was
last released on SEP 27,2007@10:19:13
Checking for unreleased
refills/partials
*** REJECT RECEIVED
FROM THIRD PARTY PAYER ***
-------------------------------------------------------------------------
Division : ALBANY
Patient : OPPAT,ONE(666-25-7941) Sex: F DOB: FEB 24,1975(32)
Prescription : 100781/1 -
FENOPROFEN 300MG CAP ECME#: 0111909
Reject Type
: 79 - REFILL TOO SOON received on DEC 21, 2007@13:20:39
Insurance : ADVANCE PSC Contact:
Group Name : D-GROUP1 Group Number: D00001
Cardholder ID: SI32432
-------------------------------------------------------------------------
Select one of the following:
O (O)VERRIDE - RESUBMIT WITH OVERRIDE
CODES
I (I)GNORE - FILL Rx WITHOUT CLAIM
SUBMISSION
Q (Q)UIT - SEND TO WORKLIST (REQUIRES
INTERVENTION)
(O)verride,(I)gnore,(Q)uit: Q//
G. Nutritional Supplement
In conjunction with IB*2*405 and PSS*1*139, this patch
PSO*7*303 provides the functionality to treat drugs marked with a DEA Special
Handling Code of “N” for Nutritional Supplement the same as supply items and
investigational drugs. Copay will not be
charged and third party billing for these type drugs will only occur when the
drug is also marked with “E” for Electronically Billable. When the drug is not defined to be electronically
billable, the ECME Log will reflect drug not billable.
ECME Log:
#
Date/Time Rx Ref Initiator Of Activity
===============================================================================
1
8/27/08@13:02:46 ORIGINAL OPPHARM,ONE
Comments: Not ECME Billable: DRUG NOT BILLABLE
A “PRESCRIPTION QUESTIONS REVIEW NEEDED” MailMan message is
sent as a result of an eligibility change since the last refill. The last paragraph of the message will be
changed to include nutritional drugs:
Subj: PRESCRIPTION
QUESTIONS REVIEW NEEDED (500) [#2123096]
09/17/08@16:27
35 lines
From: OUTPATIENT PHARMACY
PACKAGE In 'IN' basket. Page 1
*New*
-------------------------------------------------------------------------------
OPPAT,ONE (7941)
ALBANY
Eligibility: SC LESS THAN
50% SC%: 10
Disabilities: ULNA,
IMPAIRMENT OF-10%(SC),
ARTHRITIS, OTHER TYPES
(SPECIFY)-10%(NSC),
Rx# 102105 (1) COPAY
DANTROLENE 25MG CAP
Due to a change in
criteria, additional information listed below is needed
to determine the final VA
copay and/or insurance billable status for this Rx
so that appropriate action
can be taken by pharmacy personnel.
Is this Rx for a Service
Connected Condition?
This message has been sent
to the provider of record, the pharmacist who
finished the prescription
order, and all holders of the PSO COPAY key.
Enter RETURN to continue or
'^' to exit:
Subj: PRESCRIPTION
QUESTIONS REVIEW NEEDED (500)
[#2123096] Page 2
-------------------------------------------------------------------------------
Providers:
Please respond with your
answer to the question(s) as a reply to this
message. The prescription
will be updated by the appropriate staff.
Staff assigned to update
the Prescription responses:
Please use the RESET COPAY
STATUS/CANCEL CHARGES option to enter the responses
to the questions above,
which may result in a Rx copay status change and/or
the need to remove VA copay
charges or may result in a charge to the patient's
insurance carrier.
Note: The SC question is
now asked for Veterans who are SC>49% in order to
determine if the Rx can be
billed to a third party insurance. These Veterans
will NOT be charged a VA
copay.
Supply, nutritional and investigational drugs are not charged
a VA copay
but could be reimbursable by third party insurance.
Enter message action (in IN
basket): Ignore//
H. Flagged Pending Orders
For the ePharmacy Medication Profile [PSO PMP] option,
flagged pending orders will be denoted by a highlighted sequence number.
Patient Medication Profile Aug 28, 2008@14:16:11 Page: 2 of
2
OPPAT,ONE <A>
PID:
666-25-7941
HEIGHT(cm): NOT AVAILABLE
DOB: FEB
24,1975 (33)
WEIGHT(kg): NOT AVAILABLE
SEX:
FEMALE
EXP/CANCEL CUTOFF: 10 DAYS
ISSUE LAST
REF DAY
# Rx#
[v] DRUG QTY ST DATE
FILL REM SUP
13 102028$ VITAMIN B COMPLEX CAPSULE 90 DC
08-25-08 08-25-08 2 90
14 102025$e METYRAPONE 250MG S.T. 90 A
08-01-08 08-02-08 3 90
15 102023$e SIMETHICONE 40MG TAB 180 S 08-14-08 09-03-08 2 30
16 102014$e AMITRIPTYLINE 10MG TAB 180 DC
08-14-08 08-14-08 3 90
17 102013$e KAY CIEL ELIXIR 10% 1OZ 180 A
08-14-08 08-15-08 3 90
18 101957 ABSORBABLE GELATIN SPONGE S 3 A
06-11-08 06-11-08 3 90
19 101917B$e BACLOFEN 10MG TABS 180 A> 08-14-08 11-03-08 2 90
PENDING
20 AMITRIPTYLINE 10MG TAB 10 NW 03-20-08 5
10
NON-VA MEDS (Not
dispensed by VA)
21 ALBUMIN
25% 50ML Date
Documented: 03-20-08
Select the entry # to view or ?? for more actions
CV Change
View PI Patient Information SIG Show/Hide SIG
GS Group by
Status PU Patient Record Update
Select: Quit//
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