Each PBM has their own unique set of “rules” for network pharmacies to follow, and they publish these rules in their Provider Manual. Pharmacies should be aware these Provider Manuals are an extension of the Provider Agreement and contractually obligate pharmacies to adhere to these requirements. To make matters worse, PBMs update these manuals at […]
Caremark frequently issues desk audits, labeled as LTC Override Code Audits, to validate certain override codes that allow LTC pharmacies to process claims without having to call the helpdesk (generally due to early refill rejections). Submission Clarification Codes (SCC) may be input by pharmacies into NCPDP field 420-DK to identify unique dispensing situations such as […]
Each fiscal year, the Department of Health and Human Services (HHS) publishes improper payment rates for Medicare FFS Part A, Part B, and DMEPOS claims submitted between July 1 and June 30. These error rates are determined through Comprehensive Error Rate Testing (CERT) audits of a stratified, randomized sample of claims across various provider types […]
PAAS National®® analysts have received numerous calls from pharmacies related to continuous glucose monitor (CGM) products made by Dexcom, particularly the G6/G7 sensors. There appears to be two different versions of Dexcom products – those labeled for “Retail” (pharmacy benefit) and those labeled for “DME” (medical benefit). Pharmacies report finding both products on wholesaler websites […]
The CDC recently revised recommendations for COVID-19 vaccination by (i) removing the recommendation for pregnant women to receive the vaccine and (ii) that individuals ages 6 months to 17 years may receive the vaccine using a shared clinical decision-making (SCDM) approach. The SCDM recommendations are meant to be flexible and informed by the characteristics, values, […]
Numerous pharmacies have received letters from AstraZeneca, the manufacturer of Farxiga® 5 and 10 mg, regarding “discrepancies” identified in a reconciliation of purchase and dispensing data from 2024.
The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released its Semiannual Report to Congress summarizing program integrity efforts from October 2024 through March 2025 which showed a return of $11 for every $1 spent. The OIG is the lead federal agency combating healthcare fraud, waste, and abuse in federal […]
Similar to the recent package size changes for Forteo®, NCPDP reports that the FDA has requested product labeling changes on four additional products which will be revised in compendia this summer. The FDA is not requiring manufacturers to obtain new NDCs and there are no clinical changes to the products. Products with coming package size […]
When a pharmacy receives an NCPDP Reject Code 569 <Provide Notice: Medicare Prescription Drug Coverage and Your Rights> on a Medicare Part D claim, the pharmacy “must” provide the patient with the CMS-10147 form, also known as the Medicare Prescription Drug Coverage and Your Rights notice. The notice instructs enrollees about their right to contact their […]
Prime Therapeutics acquired Magellan Rx in 2022 and released the first “integrated” Provider Manual for network pharmacies in January 2024. An important change in the revised Provider Manual is the guidance for billing eye drop medications, which carries billing and audit implications.
