Dec. 21, 2012
Volume 8, Issue 3
Network Pharmacy Matters ESI Payer Sheet Updates for Jan. 1, 2013 Effective January 1, 2013, a number of payer sheet changes will be implemented for Express Scripts and legacy Medco, both in conjunction with the integration of Express Scripts and Medco and the 2013 Medicare Part D updates required by CMS. (Updates are highlighted in this article.) Changes previously announced as impacting Commercial claims only will now apply across all lines of business as appropriate.
All Medicare Part D changes outlined in this communication apply to both legacy ESI and legacy Medco.
It is critical that your systems are updated as soon as possible. Please note that Express Scripts BINS and PCNs are not changing for ESI clients and that legacy Medco BINS and PCNs remain the same. All required fields must be populated with the appropriate valid values as listed in Copies of all the payer sheets are available on the Ex- the payer sheets. press Scripts’ web portal, or you may request copies by All values submitted for all fields are validated against email to
[email protected]. See Payer Sheets, page 2
Express Scripts Adds New Plan Sponsors
E
xpress Scripts will administer the pharmacy benefits of several new plan sponsors. Plan sponsors joining Express Scripts in the 1st quarter of 2013 will have members located in the states of
New York, California, Minnesota and in St. Louis, Mo. If your company has pharmacy locations in these areas, they may experience increased member activity. EDITOR’S NOTE: Express
Scripts will no longer publish lists of new plan sponsors. However, we will continue to provide plan sponsor-specific communications as appropriate and/or at plan sponsor request.
Medicare Part D Prescriber ID Validation
E
ffective January 1, 2013, CMS will require an active, valid Prescriber NPI on all Medicare Part D claims. Express Scripts will reject invalid Prescriber NPIs submitted in field 411-DB (Prescriber ID) for all Medicare Part D claims beginning January 1, 2013. If another Prescriber ID type, such as the Prescriber’s DEA, is submitted, Express Scripts will attempt to cross-walk the submitted ID to a valid Prescriber NPI. Claims will reject at point-of-sale if:
Prescriber NPI is invalid or missing. Claim is submitted with an invalid DEA number. Prescriber DEA number cannot be crosswalked to the valid Prescriber NPI. Prescriber State License number is submitted and cannot be cross-walked to the valid Prescriber NPI. Claim is submitted on behalf of a foreign See Prescriber ID, page 2
Page 2
Network Pharmacy Matters
Volume 8, Issue 3
Prescriber ID, cont’d from page 1 prescriber without a valid NPI (Prescriber ID Qualifier “17” Submitted in field 466-EZ). The following reject codes will be returned in field 511 -FB (Reject Code) if the submitted Prescriber ID is invalid, inactive, missing, or if Express Scripts is unable to cross-walk to a valid Prescriber NPI (see table below):
Pharmacies have 90 days from date of service to research, reverse, and reprocess claims with a valid Prescriber NPI. Controlled Substance Prescribing Authority Effective January 1, 2013, Express Scripts will begin review of controlled substance claims.
Pharmacists may override rejects by providing Sub-
Per State and Federal regulations, pharmacies must validate the prescriber REJECT CODE DESCRIPTION DEA schedule for conEZ M/I Prescriber ID Qualifier trolled substances. CMS Plan’s Prescriber database indicates the Prescriber ID 42 and the Office of Inspector Submitted is inactive or is not Found General (OIG) have indi543 Prescriber ID Qualifier Value Not Supported cated a growing concern mission Clarification Code value “42” (Prescriber ID about whether prescribers have appropriate prescribing Submitted has been validated, is active) in field 42Ø- authority to write for controlled substances. DK, if the pharmacist believes the prescriber ID is active Prescriber’s registered DEA schedule must match the and valid. medication’s DEA Schedule. All claims re-submitted with SCC “42” will be returned as PAID claims with an Approved Message Code of “19” (Submitted Prescriber ID is not found or is inactive or expired – flagged for Retrospective Review) in field 548-6F. Foreign Prescriber IDs (claims submitted with a Qualifier value of “17” in field 466-EZ) cannot be overridden using the SCC of “42”. State License IDs (claims submitted with Qualifier value of “08” in field 466-EZ) cannot be overridden using the SCC “42”.
The following reject codes will be returned in field 511 -FB (Reject Code) if a submitted Controlled Substance prescription claim does not contain (see table below): A valid Prescriber DEA number, as compared to the registered DEA schedule. A Prescriber ID number that is cross-walked to a valid DEA number, as compared to the registered DEA schedule (see table below). Pharmacists may override rejects by providing one of the following Submission Clarification Code (SCC)
All claims re- REJECT CODE DESCRIPTION submitted with an Plan's Prescriber database indicates the associated DEA to 43 SCC of “42” are resubmitted Prescriber ID is inactive viewed by ESI. A Plan's Prescriber database indicates the associated DEA to 44 monthly report of insubmitted Prescriber ID Is not found valid Prescriber IDs Plan's Prescriber data base indicates associated DEA to subwill be sent to provid46 mitted Prescriber ID does not allow this drug DEA class ers for research, reversal, and reprocessing with a valid Prescriber NPI. See Prescriber ID, page 5 One Express Way St. Louis, MO 63121
Phone: 800-332-5455 Fax: 800-316-3101 Website: www.express-scripts.com
Page 3
Network Pharmacy Matters
Volume 8, Issue 3
Payer Sheets, cont’d from page 1 the NCPDP External Code List (ECL) version dated OctoField 420-DK of the Claim Segment. Submission ber 2011 and NCPDP Emergency External Code List Clarification codes are accepted in field 420-DK Version dated July 2012. Pharmacies may experience (Submission Clarification Code) to override certain a standard NCPDP reject if a VALID ECL value is not rejections as outlined in table below: entered for ALL fields. Reject Submission Clarification Claim Billing (Inbound) Reject Description Code Code Field 325-CP of the PaDUR REJECT ERROR tient Segment. Field 32588 02 = Other Override MX DOSE/DAY= xx OVR/DR APV CP (Patient Zip Code) is 03 = Vacation Supply mandatory for emergency 79 Refill Too Soon 04 = Lost Prescription or disaster situation fills, 05 = Therapy Change and should be the current zip code of the displaced patient, NOT the zip code COB Segment – Situational. COB claims require associated with his/her home address. Field 339-6C (Other Payer ID Qualifier), field 34Ø-7C Field 357-NV (Delay Reason Code) of the Claim (Other Payer ID), and 443-E8 (Other Payer Date). Segment. Field 357-NV is required when needed to Values Ø3 (BIN) and Ø5 (Medicare Carrier Number) override Reject 81 (Claim Too Old) upon submission. are accepted in Field 34Ø-7C (Other Payer ID). All valid values will be accepted, but only values Field 342-HC (Other Payer Amount Paid Qualifier) 1,2,7,8,9,10 will override the reject 81 (claim too old). in the COB Segment. Value 10=Sales Tax is an Field 419-DJ of the Claim Segment. (Prescription acceptable value for COB claims. Origin Code) is required for all claims. Accepted valid DUR/PPS Segment. For migrated plan sponsor values are listed on the payer sheet. claims ONLY, the accepted value in field 439-E4 Field 995-E2 (Route of Administration). All values (Reason for Service Code) is DD (Drug Drug) Interacsubmitted will be validated against the SNOMED CT tion; accepted values in field 440-E5 (Professional list. Service Code) are MO (Prescriber Consulted) and Field 423-DN of the Pricing Segment. Field 423-DN MA (Medication Administered—indicating the admini(Basis of Cost Determination) will reject if not popustration of a vaccine). Value 1G (Fill, with Prescriber lated with a valid NCPDP value. (All valid values are Approval) is accepted in Field 441-E6 (Result of Seraccepted.) vice Code). All other values remain acceptable for plan sponsors that have not migrated to the new sysField 466-EZ of the Prescriber Segment. If value tem. Ø8 (State License) is used in field 466-EZ (Prescriber
ID Qualifier), then fields 427-DR (Prescriber Last Name) and 367-2N (Prescriber State/Province Address) must be submitted. However, Express Scripts encourages the use of the Prescriber NPI or DEA when available. Additionally, some benefit plans may require either NPI or DEA.
New for MEDICARE PART D Claims (Legacy ESI and Legacy Medco): Fields 3Ø7-C7, 384-4X in the Patient Segment, and 147-U7 in the Claim Segment. Fields 3Ø7-C7 (Place of Service), 384-4X (Patient Residence), See Payer Sheets, page 4
Page 4
Network Pharmacy Matters
Volume 8, Issue 3
Payer Sheets, cont’d from page 3 Claims. ESI will begins rejecting invalid Prescriber ID numbers submitted for all Medicare Part D claims using reject codes EZ (M/I Prescriber ID Qualifier) or 42 (Plan’s Prescriber database indicates the Prescriber ID Submitted is inactive or is not Found) as appropriate. An active, valid Prescriber DEA is required for all Medicare Part D Controlled Substance claims. Express Scripts will reject claims if the Prescriber’s registered DEA schedule does not match the Drug’s DEA Schedule using reject codes 43 (For prescriber ID submitted, associated prescriber DEA Renewed, or In Progress, DEA Authorized Prescriptive Right), 44 (For prescriber ID submitted, associated prescriber DEA recently licensed or re-activated), or 46 (Plan's Prescriber data base indicates associated DEA to submitted Prescriber ID does not allow this drug DEA class) Field 420-DK of the Claim Segment. If your pharmacy believes a prescriber ID is active and valid but the claim is rejected, please reprocess the claim with one of the appropriate Submission Clarification Codes (SCC): 42 (Prescriber ID Submitted has been validated, is active) 43 (For prescriber ID submitted, associated prescriber DEA Renewed, or In Progress, DEA Authorized Prescriptive Right)
scriptive right for this drug DEA Class) Response Claim Billing (Outbound) Insurance Segment. The insurance segment sent in response to PAID claims now includes field 3Ø2C2 (Cardholder ID) with the ID number assigned to the cardholder. PAID claim responses will also include either field 524-FO (Plan ID) OR field 3Ø1C1 (Group ID) until all clients are moved to the new Express Scripts platform. NOTE: Subject to plan sponsor discretion; a plan sponsor may not require group ID on a claim submission. Field 548-6F and Field 132-UH of the Response Status Segment. Field 548-6F (Approved Message Code) has a new value of 019 = Prescriber ID Submitted is Not Found or is Inactive, and Field 132UH (Additional Message Information Qualifier) has new value. If 10 is returned, additional message (CCYYMMDD) will be populated in Field 526-FQ (Additional Message Information). New for MEDICARE PART D Claims (Legacy ESI and Legacy Medco): Field 393-MV of the Response Pricing Segment. Field 393-MV (Benefit Stage Qualifier) changes existing values (60, 70, 80) and adds new values 61, 62 and 90. Reversal Transaction (Inbound)
45 (For prescriber ID submitted, associated DEA is a valid Hospital DEA with Suffix)
Insurance Segment. The Insurance Segment is required for all commercial claim reversal transactions. NCPDP field 111-AM (Segment Identification) is required with a code value of 04 (Insurance), and field 3Ø2-C2 (Cardholder ID) is required with the member’s ID number as it appears
46 (For prescriber ID submitted, and associated prescriber DEA, the DEA has authorized pre-
See Payer Sheets, page 5
44 (For prescriber ID submitted, associated prescriber DEA recently licensed or re-activated)
Network Pharmacy Matters
Page 5
Volume 8, Issue 3
Records Retention Reminder Pharmacy Providers are required to maintain all Medicare Part D prescription records and supporting documentation for a minimum of 11 years (the current contract year plus 10 years). Access to Medicare Part D-related records is re-
quired for audit purposes, including audits by the U.S. Department of Health and Human Services (HHS) and the Comptroller General or its designees, or the PBM, in accordance with federal, state, and local laws, rules and regulations.
Payer Sheets, cont’d from page 4 on the member’s ID card (or as submitted on the origiIf you need assistance with processing a claim, nal claim). please call the number listed on the back of the memCOB/Other Payments Segment – Situational. This ber’s prescription drug ID card. segment has been added for reversal transactions. Express Scripts is fully committed to helping pharmaFields 337-4C (Coordination of Benefits/Other Pay- cies serve their patients, and we will continue providing ments Count) and 338-5C (Other Payer Coverage updates as the integration process moves forward. Type) must be sent for all COB claim reversals.
Prescriber ID, cont’d from page 3 values in field 42Ø-DK if the pharmacist believes the Prescriber’s DEA schedule is appropriate for the controlled substance medication prescribed (see table below): SCC CODE
DESCRIPTION
43
For prescriber ID submitted, associated prescriber DEA Renewed, or In Progress, DEA Authorized Prescriptive Right
44
For prescriber ID submitted, associated prescriber DEA recently licensed or re-activated
45
For prescriber ID submitted, associated DEA is a valid Hospital DEA with Suffix
46
For prescriber ID submitted, and associated prescriber DEA, the DEA has authorized prescriptive right for this drug DEA Class
APPROVED MESSAGE CODE
DESCRIPTION
21
For the Submitted Prescriber ID, the Associated DEA Number is Inactive – Flagged for Retrospective Review
22
For the submitted Prescriber ID, the Associated DEA Number Does Not Allow this Drug DEA Class – Flagged for Retrospective Review
Network Pharmacy Matters
Page 6
Volume 8, Issue 3
Express Scripts Employer Group Waiver Plans Express Scripts Plan Sponsors RxGroup KR4A KRQA KRUA KRVA KRXA KS2A KS3A
Service Area VA, W.VA Eastern OH, NY, NJ; Atlanta, GA; Tampa, FL; Dallas, TX; Minneapolis, MN Texas Michigan Hartford, CT; St. Paul, MN, New York, NY; Dallas, TX Illinois California
Legacy Medco Plan Sponsors RxGroup UTBMDRX VZNUMBX UMBNCRX AEPDRX MKMDRX LMMDRX DTEMDRX PSMDRX CUMINSX WEMDDRX ETSEWRX DEMEDDX GIMDRX GSMEDRX OCMDRX PCMDRX TRSEGWPRX NTCAMDX UMB16681
Implementation Date ALL BELOW 1/1/2013
RxGroup KS4A KS7A KS8A KS9A KSEA KU4A KU5A KV2A PEXA
Implementation Date ALL BELOW 1/1/2013
Service Area Tennessee National North Carolina AR, IN, KY, LA, MI, OH, OK, TN, TX, VA, WVA National National National New Jersey and Mid-Atlantic Region Indiana and National Michigan, Wisconsin NJ, DC; PR; Northern CA; Olympia, WA; Tampa, FL; Phila., PA; San Antonio, TX Delaware New York National Ohio and National National Illinois North Carolina, Virginia Michigan and National
LFGMDRX
Ft. Wayne, IN; Syracuse, NY; Radnor, PA; National
ANMEDRX BFCMDDX
VA, WVA, KY, PA, WY Kentucky
PBMDRX
Connecticut and National
BIN ALL BELOW 003858
Service Area Alabama California Maryland New York Eastern Pennsylvania Connecticut Texas Pennsylvania Illinois
BIN ALL BELOW 610014
RxGroup SAOCRX PUMEDRX BORGRX MIMDRX PBUCCRX MCMDRX MOLMDRX ACMDRX UAMDDRX MRCCRX IIMDRX CNTRYFX LTMDRX RTMDRX AGLMDRX TCOMDRX CSMDRX MOMDRX MWMDRX MONRRRX CNMDRX UBCMDRX UBCSTLX APSUMBX SWCMDRX UBCKCRX
PCN ALL BELOW MC
PCN ALL BELOW MEDDPRIME
Service Area New York, NY; Houston, TX; DC New Jersey National National Milwaukee County, WI Illinois California National Michigan California National California KY, NY; Fullerton, CA; Cleveland, OH CA, FL, GA, IL, LA, TN, TX, VA Tampa, FL New Jersey; National Ohio; National IN, KY, OH, PA Missouri; National Norwalk, CA; Greater Los Angeles, CA Ohio Greater St. Louis, Mo region (MO, IL) Arizona New York Greater Kansas City region (MO, KS)
