New Tool on PAAS Portal – Exceeding Days’ Supply Plan Limits for Unbreakable Packages
PAAS National® is continuously updating and creating new tools to help our members address common audit recoupment issues. Pharmacies frequently face recoupments due to overbilling multiple unbreakable packages or refilling claims too soon when billing for a single unbreakable package that exceeded the plan’s days’ supply limit.
The new tool, Exceeding Days’ Supply Plan Limits for Unbreakable Packages, provides a flow chart to follow based upon whether you are billing single or multiple unbreakable packages and receive a days’ supply plan limit rejection. Here is an example of each scenario:
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- Levemir® FlexPen, 15 mL (single unbreakable package), inject 35 units once daily
- 1500 units/35 units per day = 42 days’ supply but the plan limit is 30 days
- Important to clearly read the reject messaging as it can often guide you in the right direction
- If you call the PBM help desk for a days’ supply override and they deny it, then you must bill the 15 mL for a 30 days’ supply
- Be sure to make a clinical note about your call to the PBM (including their denial/refusal and if they told you a certain way to bill the claim)
- Document the calculated days’ supply in the directions for patient use
- Counsel patient and monitor refill intervals to prevent an early refill from occurring
- Creon® 24,000 (NDC 00032-2636-01), 400 capsules (multiple unbreakable packages), take 3 capsules with each meal and 1 capsule with up to two snacks per day
- 400/11 = 36 days’ supply but the plan limit is 30 days
- Per the manufacturer, Creon® must be dispensed in its original container
- Pharmacy must reduce the quantity to 300 capsules for a 27 days’ supply
- Document on the hard copy that the plan limit is 30 days
Access the new tool on the Member Portal under Proactive Tips. You can also see PAAS’ Can You Bill It as 30 Days? resource when transmitting a claim for a quantity that exceeds the plan limitations. If you have questions about Member Portal access or this new tool, please contact PAAS for assistance.
I have a Bachelor of Science degree from the University of Wisconsin-River Falls and have been a Certified Pharmacy Technician since 2001. Prior to joining the PAAS team, I was a floating technician, 3rd party district chargeback specialist, and district pharmacy training coordinator. Formerly, I was also an instructor for pharmacy technician certification classes.
PAAS’ personal, one-on-one connection will help your pharmacy become more successful in dealing with tiresome PBM audits. It is a pleasure knowing that my colleagues and I can help member pharmacies.
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