A Christmas Wish List for Claims
Here’s what I am wishing for all our health plan clients….an uneventful start to the 2015 Plan Year. By that I mean that all the prescription claims that should adjudicate without rejecting actually do, and the claims that should not pay, reject as expected. Either the beneficiary leaves the pharmacy with their medication or the pharmacist is alerted that there is a potential problem with the dose of the medication. Here are some of the issues that we have found from our reviews:
- Test claim for Unbreakable packaging logic for non-formulary drug prescription for a transition eligible member DRUG: NDC=51285008787 SEASONIQUE 0.15-0.03-0.01 TAB #91 tabs (3 months) Claim Rejects with this POS MESSAGE: “7X = DAYS SUPPLY EXCEEDS PLAN LIMITATION; MAX DS = 30 FOR TRANSITION FILL” This claim should have paid because the medication only comes in one size and is unbreakable.
- Test claim for Quantity Limit logic DRUG: NDC=59310057922 Product Description: PROAIR HFA 90 MCG 8.5 gm for 10 days supply HPMS submitted/approved Quantity Limit is 25.5/30 DS Claim Rejects with this POS MESSAGE: “88 = DUR REJECT ERROR ” Additional Reject Message: “MX DOSE/DAY= 0.54 OVR/DR APV” The claim is rejecting for max dose incorrectly based on HPMS QL of 25.5/30 or 0.85/day.
- Test claim for maximum daily dosage of Acetaminophen < 4 Grams DRUG: NDC 46672020050 HYDROCODON-ACETAMIN 7.5-325/15 Solution Claim paid for #2365 ml/10 days supply which equates to 5125 mg or 5.1 Gm of Acetaminophen/day The claim should have rejected for exceeding the maximum daily dosage of Acetaminophen.
We continually emphasize the importance of benefit administration testing and retesting as the best Part D formulary quality control effort to ensure there are no questionable claims.
Our Pharmacy experts can create and conduct an in-depth benefit administration test plan for your organization to validate that everything is working precisely as it should on an ongoing basis throughout the year. We can ensure your PBM is processing claims consistent with your CMS-Approved Prescription Drug Benefit.
I hope that your holidays are merry and bright, and that all your claims are right!
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