Professional Memo

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Memo To:

Pharmacy Network Providers

From: EnvisionRxOptions Date:

7/12/12

Number of Pages: 3 Re:

EnvisionRxOptions Pharmacy Bulletins

Dear Provider, This notification is to inform you of DUR edit’s which will be enforced for the Medicare Part D plans below, processed by EnvisionRxOptions.  x x x x

Elderplan http://www.elderplan.org HealthSun http://www.healthsun.com Samaritan Advantage http://www.samhealth.org/healthplans/medicare Simply Healthcare http://www.simplyhealthcareplans.com/medicare

Should you have any questions, please contact our Pharmacy Help Desk at 1-800-361-4542. Thank you, EnvisionRxOptions

EnvisionRxOptions Pharmacy Bulletin Below are reminders and helpful tips for Pharmacy Network Participants regarding EnvisionRxOptions‘ operational items for the 2012 plan year. Please review and post in your stores. A. Fraud, Waste and Abuse Edits EnvisionRxOptions clients may choose to apply edits for Fraud, Waste and Abuse purposes. These edits typically fall under 2 categories: 1) Max Quantity Limits 2) Max Dollar limits These edits are designed to confirm that the pharmacy is dispensing the appropriate dose and/or quantity based on the prescriber’s directions. Below is the reject messaging that you will receive at the pharmacy: Reject 76: Plan limitations exceeded - MH Reject 76: Potential FWA please call 1-866-XXX-XXXX If you receive one of these messages on a rejected claim, please contact the Pharmacy Technical Helpdesk at 1-800-361-4542 or the 1-800 number on the claim. You will be asked to confirm the drug name, dosage form, strength and directions from the prescriber. An override will be placed in the system for the claim. B. DUR Edits EnvisionRxOptions clients have the ability to reject claims based on Medi-Span DUR edits in the following categories: Therapeutic Duplication, Drug-Drug Interaction, Ingredient Duplication, Drug Age Precaution, and High Dose. Clients may select soft rejections or hard rejections to be applied to these DUR edits. When a hard rejection occurs, the only way to override the claim is to contact the Pharmacy Technical Helpdesk at 1-800-361-4542. Claims will reject in the following manner when a client has selected a soft rejection edit: Drug-Drug Interaction: Reject 88: Use DD, MO/MR, 1B/1G. For >1 alert use 00000000003 Dose Check-High Dose Interaction: Reject 88: Use HD, DE/MO/MR, 1B/1G. For >1 alert use 00000000003 Drug-Age Interaction: Reject 88: Use PA, MO/MR, 1B/1G. For >1 alert use 00000000003 Drug-Sex Interaction: Reject 88: Use SX, MO/MR, 1B/1G. For >1 alert use 00000000003 Duplicate Drug: Reject 88: Use ID, MO/MR, 1B/1G. For >1 alert use 00000000003 Duplicate Therapy: Reject 88: Use TD, MO/MR, 1B/1G. For >1 alert use 00000000003 When a client selects a soft rejection the rejection may be overridden in one of 2 methods: Method 1: The pharmacy populates the following fields with NCPDP standard service codes to override the DUR reject: Professional Service Code NCPDP field = 44Ø-E5. Reason for Service Code NCPDP field = 439-E4. Result of Service Code NCPDP field = 441-E6.

DUR Conflict Code TD DD ID PA HD

Description

Prof Service Code MR

Reason for Service Code TD

Result of Service Code 1B

Therapeutic Duplication Drug-Drug Interaction Ingredient Duplication Drug Age Precaution High Dose

MR

DD

1B

MR

ID

1B

MR

PA

1B

MR

HD

1B

The DUR conflict code should be the deciding factor on which combination of service codes are submitted to override the rejection Method 2: In certain circumstances, when there are multiple DUR edits on a claim, pharmacies will be able to submit a prior authorization code consisting of 00000000003 (10 zeros and then the number 3) at point of sale.