Title: Class
1Welcome to Class 319 ePharmacy - Advanced
(Million Dollar Baby) VEHU 2007
2ePharmacy Faculty
- Greg Laird
- Judy Petersen
- Janet Graham
3ePharmacy Objectives
- By the end of todays session youll be able to
- Understand how ePharmacy processes CMOP and Local
Mail Out transactions - Realize the importance of ePharmacy messages
- Be aware of the OPECC ECME User Screen
- Recognize the significance of the ePharmacy
parameters and reports - Know how to find ePharmacy resources
4Overview
5e-Pharmacy Overview
- e-Pharmacy is the real-time processing of
electronic prescription claims from VistA to
Third Party Payers - Electronic processing of third party claims is a
HIPAA requirement - ePharmacy transactions only take place when
Veteran has Prescription Insurance and Rx is
billable - Payers provide an immediate adjudicated response
- Claim is marked payable or rejected
- Average response time 18 seconds
6e-Pharmacy Overview
- Staff Pharmacists resolve Drug Utilization Review
(DUR) or Refill Too Soon (RTS) rejects - ePharmacy claims for CMOP and Local Mail Outs
processed as part of background job - DUR RTS rejects from this process are sent to
Third Party Payer Rejects - Worklist for
resolution by ePharmacy Site Manager - Revenue Staff responsible for resolving all other
rejects - Insurance Verifiers responsible for maintaining
Veteran insurance information
7ePharmacy - Under the Hood
8Processing Window Fills
9Window Fill - Payable
10Window Fill - PayableRx Label Prints
11Window Fills Transmission
12Window Fill RejectedReason Invalid Ins, NDC,
Days Supply, etc.
13Window Fill RejectedReject to OPECC / Rx Label
Prints
14Window Fills Transmission
15Window Fill RejectedReason Refill Too soon
or DUR
16Window Fill Rejected Reject to Users screen /
NO Rx Label Prints
17Window Fill Rejected Reject resolved / Rx
Label Prints
18ePharmacy - Under the Hood
19CMOP Transmissions
- Before e-Pharmacy Activated
20CMOP Transmission Processbefore e-Pharmacy
21Prescriptions transmitted to CMOP
22CMOP Transmissions
- After e-Pharmacy Activated
23e-Pharmacy Steps added to CMOP Transmission
process
24e-Pharmacy evaluation occurs on Prescriptions
25Payers adjudicate e-Pharmacy claims
26Wait Time built in to process
27Prescription 1 is Non-BillableRx sent to CMOP
28Prescription 2 is PayableRx sent to CMOP
29Prescription 3 Non-Billable (Null DEA)Rx sent
to CMOP
30Prescription 4 No Payer Responsee-mail sent to
Key holders / Rx kept in CMOP queue
31Prescription 5 Rejected Invalid NDCReject
sent to OPECC / Rx sent to CMOP
32Prescription 6 Rejected Refill Too SoonReject
sent to Third Party Reject Worklist
33Recap Status of Six Prescriptions
34CMOP Transmission Today 1
35CMOP Transmission Today 1
36CMOP Transmission Today 2
37CMOP Transmission Today 3
38NDC Change - CMOP
- Rx Activity Log Jul 26, 2007_at_125419
Page 4 of 6 ECME, Patient One PID
-- Ht(cm) 175.26
(03/14/2007) DOB
Wt(kg) 67.91 - ECME Log
Date/Time
Rx Ref Initiator Of Activity
1
6/25/07_at_191806 REFILL 3 RPH,ONE P
Comments Submitted to
ECMECMOP TRANSMISSION(NDC00006-0072-31)
2 6/25/07_at_222134 REFILL 3
POSTMASTER Comments
Submitted to ECMECMOP RELEASE(NDC00378-3151-93)
- Enter ?? for more actions
Select ActionNext Screen//
39Final Recap Six Prescriptions
40Local Mail
- Local Mail Label Print before ePharmacy
- Local Mail Label Print after ePharmacy
- 1st Step
- Wait Time
- 2nd Step
41Local Mail Label Printbefore e-Pharmacy
42Local Mail Label Printafter e-Pharmacy 1st step
43Local Mail Label Print - Wait Time
44Prescription 1 is Non-BillableRx sent to Label
Printer
45Prescription 2 is PayableRx sent to Label
Printer
46Prescription 3 Non-Billable (Null DEA)Rx sent
to Label Printer
47Prescription 4 No Payer ResponseNo e-mail sent
/ Rx kept in Suspense queue
48Prescription 5 Rejected Invalid NDCReject
sent to OPECC / Rx Label prints
49Prescription 6 Rejected Refill Too SoonReject
sent to Third Party Reject Worklist
50Recap Six Local Mail Prescriptions
51Pull from Suspense Today 1
52Process RTS Reject Today 1
53Process DUR Reject Today 1
54Pull from Suspense Today 2
55Pull from Suspense Today 3
56Final Recap Six Local Mail Rxs
57ECME User Screen
58ECME User Screen
Select ECME Option U ECME User Screen
MGR Pharmacy ECME Manager Menu ... RPT
Pharmacy Electronic Claims Reports ... Select
ECME Option U ECME User Screen Please wait...
59ECME User Screen
- PHARMACY ECME Jun 05, 2007_at_141512
Page 1 of 6 - SELECTED DIVISION(S) ALL
- Transmitted by ALL users Activity Date
Range within the past 7 day(s) -
Sorted by Insurance - PATIENT/DRUG/COMMENTS INSURANCE/NDC/RX/ECM
E LOC/TYP RXINF - 1 ONE,ECME PATIENT (XXXX) AETNA PH/800
238-6279 Done Pb0 Rj6 AcRv0 RjRv0 - 1.1 HYDROCHLOROTHIAZIDE 50 65243-0040-09
51413205C 3/9631034 C RT ACT/RL - Rejected
- 54Non-Matched Product/Service ID Number
- To dispute this claim, call 1-800-238-6279
for forms and instructions - 1.2 OMEPRAZOLE 20MG SA CAP 62175-0118-43
51513913A 3/9631038 C RT ACT/RL - Rejected
- 70Product/Service Not Covered
- RX not covered- consider Prilosec OTC. To
dispute this claim, call 1-800-2 - 38-6279 for forms and instructions
- 1.3 SIMVASTATIN 40MG TAB 00006-0749-82
51399898C 3/9631040 C RT ACT/RL - Rejected
- 76Plan Limitations Exceeded
- Enter ?? for more actions
60ECME User Screen Sort List
- CU Continuous Update REV Reverse Payable Claim
FR Further Research - UD Display Update RES Resubmit Claim
PD Print Data - CV Change View CLO Close Rejected Claim
LOG Print Claim Log - SO Sort List CMT Add/View Comments
EX Exit - Select Action Next Screen//SO Sort List
- Select one of the following
- T TRANSACTION DATE
- D DIVISION
- I INSURANCE
- C REJECT CODE
- P PATIENT NAME
- N DRUG NAME
- B BILL TYPE (BB/RT)
- L FILL LOCATION
- R RELEASED/NON-RELEASED
- A ACTIVE/DISCONTINUED
61ECME User Screen
- PHARMACY ECME Jun 05,
2007_at_150636 Page 1 of 7 - SELECTED DIVISION(S) ECME DIVISION
- Transmitted by ALL users Activity Date
Range within the past 5 day(s) -
Sorted by Reject Code - PATIENT/DRUG/COMMENTS
INSURANCE/NDC/RX/ECME LOC/TYP RXINF - ---- Reject code 19M/I Days Supply
------------------------------------------ - 1 ECME, PATIENT ONE (YYYY) CAREMARK/800
345-5413 Done Pb0 Rj2 AcRv0 RjRv0 - 1.1 MINOCYCLINE HCL 50MG C 00093-3165-01
51293352C 3/9555018 C RT EXP/RL - Rejected
- 76Plan Limitations Exceeded
- 19M/I Days Supply
- Maximum Days Supply of 60 RX
IS OVER ONE YEAR OLD - 1.2 LEVOTHYROXINE NA (SYNT 00074-9296-19
51293349C 3/9558187 C RT ACT/RL - Rejected
- 76Plan Limitations Exceeded
- 19M/I Days Supply
- Maximum Days Supply of 60
- 2 ECME, PATIENT TWO (ZZZZ) AETNA PH/800
238-6279 Done Pb0 Rj4 AcRv0 RjRv0
62Parameters, Bulletins and Reports
63Auto Reversal Process
- It is critical to release all billable
prescriptions filled in a timely manner - Otherwise VA may receive payments for
prescriptions never filled - ECME Auto Reverse Parameter defines the number of
days the system will wait before the ePharmacy
sends a reversal transaction to the payer - Exceptions
- Prescriptions filled as given in clinic should
not be released. - The ECME Auto reversal should occur on these Rxs
since we should not bill the third party for
these medications. - ECME Auto Reverse process reverses claims for
outpatient prescriptions processed for inpatients - (example self-medication programs)
64ECME Parameters
- ECME Parameters
- Auto-reverse parameter
- Can be set for 0-30 days
- Most sites set at 4 days
- Work with OPECC and Accounts Receivable staff to
determine best setting - ECME Timeout
- Has to do with the number of seconds
transmissions will go on before user is allowed
to go to next task - Can be set for 0-30 seconds
- Most sites set at 30 seconds
65Through Days and Pull Ahead Settings
- Pharmacy parameters control when Rxs sent to
CMOP - CMOP Thru Days CS Transmission
- CMOP Thru Days Non-CS Transmission
- Days to Pull Suspended CS CMOP
- Days to Pull from Suspense
66CMOP Thru Days Parameters
- CMOP Thru Days CS Transmission
- CMOP Thru Days Non-CS Transmission
- Daily process identifies all Prescriptions in the
Suspense file with Fill dates that fall within X
days in the future for transmission to CMOP. - Parameters allow time for prescriptions to be
transmitted, processed and mailed to a patient. - Each can be set for 0 to 10 days
67Outpatient Days to Pull Parameters
- Days to Pull Suspended CS CMOP
- Days to Pull from Suspense
- Used to find additional prescriptions for the
patients identified by the CMOP Thru Days
process. The purpose is to help minimize mailing
costs. - Each can be set for 0-10 days
Example Patient One has 3 prescriptions
identified by the CMOP Thru Days process. The
system now looks to see if Patient One has
additional prescription will Fill Dates X days in
the future to add to the CMOP Transmission. (X
the divisions Days to Pull number)
68Why are these parameters important?
- The pull ahead parameters have an impact on the
Date of Service used on an e-Pharmacy claim. - We dont recommend changing your parameters
initially - Remember, e-Pharmacy prescriptions will be a
small percentage of your total suspended
prescription volume. - Changing parameter sessions can be considered if
you see a significant number of RTS rejects
69Pull Ahead Settings at Six ePharmacy Sites
70ePharmacy Bulletins
71CMOP Not Transmitted Message
- Subj ePharmacy - CMOP Not TRANSMITTED Rx List
55657173 07/24/07_at_1844 - 15 lines
- From POSTMASTER In 'IN' basket. Page 1 New
- --------------------------------------------------
------------------------ - The prescriptions listed below are third party
electronically billable. - They have not been transmitted to CMOP because
they have been submitted to - third party payer but we have not received a
response regarding these - prescriptions yet. The prescriptions will remain
in the CMOP queue to be - transmitted in the next transmission if the
response from the third party - payer has been received.
-
- Division ECME TEST
- --------------------------------------------------
----------------------------- - RX/Fill PATIENT(LAST4SSN) DRUG
FILL DATE - --------------------------------------------------
----------------------------- - 52593020A/0 ECMEpatient,One(0000) FORMOTEROL
FUMARATE 12MCG Jul 29, 2007 -
- Total ECME TEST 1 Patients and 1 Prescriptions.
-
Bulletin sent to users who hold the PSXMAIL
security key.
72Auto-Reversal e-Mail Message
- Subj ECME AUTO-REVERSAL PROCESS 55682790
07/09/07_at_0100 12 lines - From BPS PACKAGE In 'IN' basket. Page 1
New - --------------------------------------------------
------------------------- - The ECME Nightly Process completed auto-reversals
for the following e-Pharmacy prescriptions. -
- TOTAL AUTO-REVERSED CLAIMS 3
-
- Claims Auto-Reversed on 07/09/06
-
- RX FILL STATUS FILL DATE PATIENT
BPS PHARMACY - --------------------------------------------------
------------------------- - 1 987654321 1 W/RL 07/03/07 TEST,PATIENT
ONE ECME 2 TEST - 2 123456789C 2 C/NR 07/14/07 TEST,PATIENT
TWO ECME TEST - 3 787878787 1 M/RL 07/03/07 TEST,PATIENT
THREE ECME 2 TEST - --------------------------------------------------
------------------------- -
- Enter message action (in IN basket) Delete//
Bulletin sent to members of the G.BPS OPECC mail
group
73RX Not Processed
Subj RX not processed for site ECME TEST VAMC
4757272 07/01/07_at_1253 11 lines From BPS
PACKAGE In 'ECME' basket. Automatic Deletion
Date Aug 30, 2007 Page 1 New -----------------
--------------------------------------------------
----------- Prescription 4150294 and fill number
0 could not be processed because the previous
request was in progress. There may have been a
delay in processing of the previous claim or the
previous claim may be stranded. For more
information on this prescription's activity,
please view the ECME log within the View
Prescription (VP) option on the Further Research
(FR) menu of the ECME user screen. Patient
Name ECMEpatient,One Last four digits of SSN
0000
Bulletin sent to members of the G.BPS OPECC mail
group
74ePharmacy Reports
75Claims Submitted, Not Yet Released Report
-
-
- Electronic Claims Management
Engine (ECME) V1.0 - ECME TEST DIV
- Claim Results and
Status -
- PAY Payable Claims Report
- REJ Rejected Claims Report
- ECMP CMOP/ECME Activity Report
- REV Reversal Claims Report
- NYR Claims Submitted, Not Yet Released
- REC Recent Transactions
- DAY Totals by Date
- CLO Closed Claims Report
76Results of Not Yet Released Rx Report
- DIVISION PATIENT NAME RX DATE DRUG FILL
LOCATION - ECME TE ECME,ONE PATI 564477 6/30/07
CITALAPRAM 20MG M - ECME TE ECME,TWO PATI 564544 7/01/07
OXYCODONE 10MG W - ECME TE ECME,THREE PA 564621 7/02/07
DIGOXIN 0.2MG C - Other fields, including insurance and
reimbursement information, can be printed on this
report.
77ePharmacy Automation
78Automation/OPAI Lessons
- HL7 Complete Message
- Does it exist for the Rx?
- Is the RXD segment correct?
- NDC
- Does the vendor system return the actual NDC?
- Is it an 11-digit number?
- File 52
- Rx released (auto or manual) vs unreleased
- Field 27 (for Original)
- Field 52, Subfield 11 (for Refills)
- Vendor Dispensing Reports
79McKesson/Parata Automation
- Working with test sites
- Testing OPAI with McKesson/Parata
- Test ePharmacy with McKesson/Parata OPAI
80ePharmacy Challenges Resources
81Challenges
- Days Supply Rejects
- 90 day fills main issue
- More payers are accepting now
- Invalid NDC rejects
- Main problem is with re-packagers NDCs not being
recognized by third parties - Problems getting Data Management company (First
Databank Medispan etc.) files updated for NDC - Much progress has been made
- Dispensing units a problem
- Third parties want insulin quantities expressed
in ml and inhalers in gms - VA uses unit of
each - Temporary fix currently being tested
82Challenges (continued)
- Billing Tricare and ChampVA
- These claims use a cost plus fee billing
structure - VA will not dispense Rx if claim not payable
- Working on requirements for a future enhancement
- Patient inquiries and concerns
- Patients know their copays are reduced by monies
collected from third party - Third Parties send EOBs to the patient providing
the status of the claim, e.g., Invalid NDC - Patient may have to make a VA copayment when
they previously did not have to when a paper
claim was submitted for the same drug - Patients sometimes call Pharmacy about third
party processing questions
83Educational Resources
- ePharmacy User Support Calls VANTS 82429
- 2nd 4th Monday of each month _at_ 11 am Eastern
- VistA University ePharmacy Training Page
- http//vaww.vistau.med.va.gov/VistaU/e-bp/e-pharma
cy.htm - Live Meeting Sessions
- e-Pharmacy Checklists
- Show-Me videos
- ePharmacy Simulation Training located on VA
Employee Education System On-Line Learning
Website - https//vaww.ees.aac.va.gov/librix/loginhtml.asp?v
librix - OIT Project Website
- http//tspr.vista.med.va.gov/warboard/anotebk.asp?
proj699TypeActive - VISN POCs
84 Questions?