Per NCPDP’s Telecommunication Version D and Above: Questions, Answers and Editorial Updates, “the Prescription Origin Code (419-DJ) contains the value that represents the method in which the pharmacy originally received the prescription from the prescriber.” Any subsequent changes or modifications to the original prescription do not change the origin code even when clarifications of that […]
PAAS National®® continues to see a large number of EPIPEN® prescriptions flagged for audit, as well as targeted on OptumRx prescription validation requests. The PBMs often target EPIPEN® products due to their higher cost and confusion around proper billing practices and product substitution. Adhering to the guidance below can help avoid billing issues and reduce […]
As the flu shot season starts, PAAS National®® wants to make sure you are ready to properly document these routine vaccines in case of an audit. Now is the time to check that you have all required documentation in place for this year’s flu shot season. What is needed upon an audit:
In the PAAS National®® January 2025 Newsline article, PBM Prescription Validation Requests – What Are They Looking At Now? we discussed the PBM trends we saw in 2024. Below is a list of drugs reviewed and analyst comments that have been compiled through the first six months of 2025 along with a comparison from 2024. […]
Calling a prescriber’s office due to a prescription with missing elements, or needing clarification, is an inescapable task. If you are failing to document that phone call with a valid clinical note, PBMs may flag the claim upon audit and try to recoup. We have seen OptumRx, Humana, Navitus, and ESI/Prime results citing pharmacy clinical […]
If you are a DMEPOS supplier billing Medicare Part B claims, then you should be familiar with the proof of refill request requirement. All DMEPOS items and supplies billed to Medicare Part B that are delivered or mailed require proof of refill request and an affirmative response to occur and be documented prior to shipment. […]
Nayzilam® and Valtoco® are indicated for the short-term treatment of seizure clusters that are distinct from a patient’s usual seizure pattern in patients with epilepsy.
There are currently three FDA-approved Respiratory Syncytial Virus (RSV) vaccines available for individuals at risk of severe illness from a respiratory virus. Please review the chart for helpful billing tips and the additional information below as to which RSV vaccine is appropriate to give to an eligible individual.
Pharmacies continue to receive PBM audit notices for claim recoupments where the [allegedly] improper Medicare coverage was billed. Medicare Part A helps cover hospital, skilled nursing facility (SNF), and hospice care stays. Medicare coverage status is typically linked to the patient’s admission and discharge dates from a Part A stay. When a patient is covered […]
The CMS-10147 Form, also known as the Medicare Drug Coverage and Your Rights Notice, must be distributed to Medicare Part D beneficiaries when a prescription is not covered at the point-of-sale. This notice informs beneficiaries about their right to contact their Part D plan to request a coverage determination, including an exception. The distribution of the […]
