Express Communications September 5, 2012 Page 1 of 5
Express Scripts Migrating Additional Plan Sponsors Announcement:
As we continue updating you on changes that are occurring now that Express Scripts and Medco are one company, effective October 1, 2012, another group of Express Scripts’ COMMERCIAL plan sponsors will be migrated to the new adjudication system of the combined company. For migrated Express Scripts member claims: Please follow the processing information indicated on the member ID cards, including submission of the ID number exactly as it appears on the card. Inconsistencies will result in a rejection. The BINs and PCNs are not changing for migrated ESI members; it is business as usual and claims will be routed to the correct platform.
Information for Pharmacies:
The Express Scripts Commercial Payer Sheet, which you have received in prior communications, has not undergone any further material changes. (The updated payer sheet is available on the Express Scripts’ web portal and by email request to
[email protected].) For more information, please refer to the FAQs beginning on page 3 of this communication. For legacy Medco member claims: At this time, there are no changes for processing legacy Medco member claims. However, the Express Scripts logo may begin appearing on member ID cards that contain legacy Medco processing information – again, please use the processing information indicated on the card. Please follow the legacy Medco payer sheets if submitting a claim to the Medco BIN. (The legacy Medco payer sheets have not changed.) Your system should be updated to populate the additional REQUIRED fields on the updated Express Scripts Commercial payer sheet for both In-bound Billing and Reversal Transactions that were previously identified as optional or not included. These required fields must be populated with the appropriate valid values as listed in the payer sheet.
System Reminders:
Your system should also be able to receive the additional fields on the updated Commercial Payer Sheet in the Outbound Billing Response since ESI did not previously return these fields. All values submitted for all fields are now validated against the NCPDP External Code List (ECL). Pharmacies may experience a standard NCPDP reject if a VALID ECL value is not entered for ALL required fields. Pharmacies may see different reject codes returned on migrated plan sponsor claims; however, all reject codes will be standard NCPDP values. Confidential & Proprietary
© 2012 Express Scripts Holding Company. All Rights Reserved.
Express Communications September 5, 2012 Page 2 of 5
Express Scripts Migrating Additional Plan Sponsors
Pharmacy Portal:
Beginning October 1, 2012, when the next group of Express Scripts plan sponsors transition to the combined adjudication system, their members‟ claims will no longer be visible on the Express Scripts pharmacy portal. However, these claims will be visible on the Pharmacy Resource Center (legacy Medco web portal). If you do not have access to the Pharmacy Resource Center at www.medco.com/rph, please take a few minutes to register. (For now, all Express Scripts member claims that have NOT migrated continue to be accessible on the Express Scripts pharmacy portal at www.express-scripts.com/corporate.)
For More Information:
If you need assistance with processing a claim, please call the number listed on the back of the member’s ID card. (Please also review the updated FAQs beginning on page 3 of this communication.) Express Scripts is fully committed to helping pharmacies serve their patients, and we will continue providing updates as the integration process moves forward.
Confidential & Proprietary
© 2012 Express Scripts Holding Company. All Rights Reserved.
September 5, 2012 Page 3 of 5
Frequently Asked Questions for Pharmacies Q. Which plan sponsors have migrated or are migrating? There are no processing changes for migrated plan sponsors’ member claims. It is important to continue referring to the processing information on the member’s ID card. Q. Is the attached Commercial Payer Sheet final? It is the final Commercial Payer Sheet until further notice, but there may be additional changes as the integration progresses. Q. Do the Commercial Payer Sheet changes apply to all ESI-supported BINs or just 003858? The attached payer sheet applies to ALL Express Scripts commercial plans, including the following BIN numbers: BIN ØØ3858 61Ø575 Ø1355Ø 61ØØ53
Description Express Scripts WellPoint Commercial WellPoint Commercial WellPoint Commercial
BIN Ø1Ø991 Ø13865 4ØØØ23 Ø1ØØ33
Description Emblem – Teamsters Local 237 Emblem – GHI Commercial Emblem – HIP Commercial Emblem – Vytra Health Plan
Q. Does the updated payer sheet apply to all Express Scripts commercial plan sponsors or only to those that have been migrated to the new adjudication platform? The updated payer sheet applies to ALL Express Scripts commercial plan sponsors. You do not need to differentiate between plan sponsors migrated to the new adjudication platform and those that remain on the existing ESI platform. The changes will be accommodated on both the new platform and the legacy ESI platform. Q. Will I receive plan information for PAID claims in field 3Ø1-C1 (Group ID) and field 524-FO (Plan ID)? No. You will receive plan information in only one of these fields. Express Scripts is moving to field 3Ø1-C1 (Group ID) to return plan information for PAID claims. For those clients migrating to the new platform, plan information will be returned in the Group ID field. Until clients migrate to the new ESI platform, plan information will continue to be returned in field 524-FO (Plan ID). Q. If a claim is submitted to an Express Scripts BIN, will the Medco website address be returned on the rejected response? Yes, the Medco web address will be returned for migrated plan sponsor claims ONLY. Q. Why am I receiving an „E2‟ reject code (M/I Route of Administration)? Express Scripts now validates all submitted values against standard NCPDP External Code List (ECL) values. This includes validation of SNOMED codes submitted in field 995-E2 (Route of Administration). Q. Why am I receiving a „DN‟ reject response for field 423-DN (Basis of Cost Determination)? While Express Scripts previously indicated field 423-DN as a required field on its payer sheet, the new platform has an edit in place to reject the claim if this field is not populated, or is populated with an invalid NCPDP value. Q. The segment “Reversals: COB/Other Payments Segment – Situational” has been added to the Commercial Payer Sheet for reversal transactions, and fields 337-4C (Coordination of Benefits/Other Payments Count) and 338-5C (Other Payer Coverage Type) must be sent for all COB claim reversals. Will Express Scripts accept these fields both for claims that have NOT migrated as well as for those that have migrated? Yes. The claim will reverse on both systems when these COB fields are submitted.
Confidential & Proprietary
© 2012 Express Scripts Holding Company. All Rights Reserved.
September 5, 2012 Page 4 of 5
Frequently Asked Questions for Pharmacies (Continued) Q. Submission Clarification codes will now be accepted in field 420-DK (Submission Clarification Code) of the Claim Segment to override certain rejections as outlined below: Reject Code 88 79
Reject Description DUR REJECT ERROR MX DOSE/DAY= xx OVR/DR APV
Submission Clarification Code 02 = Other Override 03 = Vacation Supply 04 = Lost Prescription 05 = Therapy Change
Refill Too Soon
If the pharmacy enters the codes in field 420-DK, does this mean they would not need to call the Pharmacy Help Desk and will replace the need to manually issue overrides for these rejections? Yes. The pharmacy can enter these codes without calling the Help Desk for claims processed on the new platform. Q. What will happen to all other DUR alerts we currently receive (e.g. TD-Therapeutic Duplication, PG Pregnancy, Age) when plan sponsor claims are migrated? Most of the DUR alerts, including therapy duplication, pregnancy, age, low dose, will generate a warning at point-of-sale. Most drug-drug interactions and high dose alerts will continue to reject. Ingredient duplications check will continue to be performed, but will now be incorporated into Therapy Duplication checks. Q. If I have questions regarding submission of a claim, what number should I call? Claims submitted prior to September 1, 2012 for the upgraded members indicated on page 1 of this communication will no longer be viewable on the Express Scripts pharmacy portal. If you have questions or need assistance processing one of these claims, please call the pharmacy help desk number indicated on the back of the member’s prescription drug ID card. For assistance with claims submitted on or after September 1, 2012, please access the legacy Medco Pharmacy Resource Center web portal at www.medco.com/rph. Q. Will my remittance change with this plan sponsor upgrade? If so, how? Pharmacies that submit claims for the Express Scripts’ plan sponsors that have been upgraded will be reimbursed for those claims with their legacy Medco remittance. As the integration progresses and more plan sponsors are upgraded, providers may receive multiple remittances. We will keep you informed by communicating any changes in advance. Q. How will I be reimbursed for Professional Service Fees (PSFs) on upgraded vaccine and compound claims? For upgraded claims identified as vaccines or compounds, your PSF reimbursement will appear as line item CREDIT adjustments on your legacy ESI remittance. As noted above, however, your reimbursement for upgraded claims will appear on your legacy Medco remittance. We will advise you when the remittance will be updated to include the PSF reimbursement (along with the claim reimbursement) for upgraded members. Q. On which remittance will transaction fees be deducted for upgraded claims? All transaction fees for claims processed, regardless of whether or not the plan sponsor has been upgraded, will be deducted from your legacy Express Scripts remittance. For upgraded members, the transaction fee will appear as a line item debit on the legacy Express Scripts remittance. NOTE: The remittance changes impacting upgraded compound claims, vaccine claims and transaction fees (as noted above) will appear 14 days after submission of the claim at point-of-sale. Again, this is an interim solution as we combine our companies, and we will advise you of any future changes. Q. Will I be able to access claims on the Express Scripts‟ pharmacy portal for upgraded members? No. Beginning September 1, 2012, upgraded member claims will no longer be viewable on the Express Scripts pharmacy portal. However, messaging on the portal will direct providers in how to access the correct information.
Confidential & Proprietary
© 2012 Express Scripts Holding Company. All Rights Reserved.
September 5, 2012 Page 5 of 5 Q. Why am I now receiving different reject codes? All reject values returned are standard NCPDP reject codes. For example, a prescription claim that previously rejected with 70 (Product/Service Not Covered) may now reject for 4W (Must Fill through Specialty Pharmacy) based on plan set-up. The table below lists all the reject code changes for migrated members.
Prior NCPDP Reject Code
Prior NCPDP Reject Message
New NCPDP Reject Code
New NCPDP Reject Message
19
(M/I Days Supply)
76
(Plan Limitations Exceeded)
19
7X
(Days Supply Exceeds Plan Limitation)
4W
(Must Fill Through Specialty Pharmacy)
76
(M/I Days Supply) (Product/Service Not Covered – Plan/Benefit Exclusion) (Product/Service Not Covered – Plan/Benefit Exclusion) (Plan Limitations Exceeded)
76
(Plan Limitations Exceeded)
70 70
9G 7X 9G
(Quantity Dispensed Exceeds Maximum Allowed) (Days Supply Exceeds Plan Limitation) (Quantity Dispensed Exceeds Maximum Allowed)
Q. Why am I receiving a „28‟ reject response for field 414-DE (Date Prescription Written)? While Express Scripts previously indicated field 414-DE as a required field on its payer sheet, the new platform has an edit in place to reject the claim if this field is not populated, or is populated with an invalid date value. The “date prescription written” MUST be no greater than one year prior to the current date. For example, if a claim is submitted on 9/1/2012, the date the prescription was written should not be earlier than 9/1/2011. There may be additional edits on this field for controlled substance prescriptions depending on state and plan sponsor requirements.
Confidential & Proprietary
© 2012 Express Scripts Holding Company. All Rights Reserved.
