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 Part D plan to request a “coverage determination” or prior authorization.
In general, all pharmacies must arrange for this form to be distributed to the patient. While retail pharmacies must provide the notice at point-of-sale, mail order and specialty pharmacies have up to 72 hours to provide it to the patient. Importantly, CMS recognizes the uniqueness of LTC settings and that there is no practical means to deliver the notice directly to the patient; as a result, if the pharmacy can resolve the matter and ensure the LTC patient receives the needed medication or an appropriate substitute, they do not need to deliver the notice. If the matter cannot be resolved, then the pharmacy must deliver the notice within 72 hours to the patient, patient’s representative, prescriber or appropriate staff person at the LTC facility.
The 569 reject will NOT be returned in the following scenarios:
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Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
- Access Services
- Audit Documentation Submission Guidance
- An online form to submit safe filling and billing questions
- Your PAAS Membership Manual
- Newsline
- Monthly newsletter articles, written by our expert PAAS analyst team, provide safe filling and billing tips and relays relevant/current PBM trends to be help prevent audits
- Search the Newsline Archive to get PAAS tips at the click of a button
- Special Edition Newslines including: Top 10 articles of the prior year, DMEPOS Article Series and a Self-Audit Article Series
- Ability to print monthly issues or individual articles
- Proactive Tips
- Audit flags – list of various claim attributes the PBMs use to select claims for audit
- Billing insulin vials – flowchart to assist whether you should bill Medicare Part B vs Part D
- DAW Codes Explained – use to understand when to effectively use DAW codes, their definitions and why claims may be flagged for audit if a DAW code is used incorrectly
- Basic DMEPOS documentation guidance
- Onsite Credentialing Checklist and expanded definitions of policies and procedures
- Proof of refill request and affirmative response form for DMEPOS items
- Steps on how to prepare for an onsite audit
- And more!
- Days’ Supply Charts
- Utilize the days’ supply charts for inhalers, insulins, nasal sprays, eye drops and topicals to aid you in calculating the correct days’ supply
- Guidance on overbilled quantities and incorrect days’ supply account for a sizable portion of audit chargebacks
- Additional miscellaneous charts, which include: Dispense in Original Container and Return to Stock
- Forms
- Signature Logbook for print
- Signature Trifold Mailer
- Fax and Email Coversheet
- Patient Attestation for over-the-counter COVID-19 test kits
- On-Demand Webinars
- Short webinars on hot topics in the PBM industry. Here are a few examples:
- USP 800 Compliance
- Cultural Competency Training
- Dispensing Prescriptions Off-Label
- Biologic Medications and Interchangeability
- Continuous Glucose Monitor Requirements for Medicare Part B
PAAS Tips:
- MORE AUDITS, MORE INSIGHT – PAAS National® is the industry-leading defender of community pharmacy dealings with Prescription Benefit Programs, including Caremark, Express Scripts, Humana, Medicaid, OptumRx, Prime Therapeutics., and more. PAAS assists on all third-party audits, including: desktop audits, onsite audits, invoice audits, OIG/Medicaid audits, Medicare B audits. The PAAS team is dedicated to helping you! We have five pharmacists and a complement of technician analysts with over 50 years of dedicated audit assistance experience. PAAS continuously updates their database with every audit received — in fact, we even keep a scorecard on individual auditors.
- Get answers to your questions on days’ supply calculations, drug substitutions, billing practices, required documentation, prior authorization requirements, record retention, and internal audit procedures – just to name a few. As a trusted partner, we will provide tailored guidance to help you proactively prevent audits. Remember, the prescription claims you submit today are the audits of the future.
- Keep your employees engaged and help lower audit risk by adding all employees to the portal and giving them permission to access these tools, resources and eNewsline. For more information review September 2019 Newsline article, What Are You Waiting For? Make Sure ALL of Your Employees are Added to the PAAS Portal!
- Contact PAAS at (608) 873-1342, if you would like a tour of your PAAS Member Portal, so you can reap all the benefits of your PAAS Audit Assistance. We appreciate you being a member.
From Headache to Hassle Free: Best Practices in Migraine Medication Billing
Migraine medications continue to be targeted for audit by all PBMs. With new products on the market, rising costs, and frequency of refills, PBMs are looking for billing errors to claw back payments on audit.
OptumRx’s latest tactic…
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Bowel Prep Kit Billing Under CMS Review: PBMs in Focus
Recent CMS audits have brought renewed attention to how PBMs oversee pharmacy billing for bowel preparation kits. Common issues listed below are leading to potential compliance violations and recoupments. Pharmacies and PBMs alike are urged to review current practices to ensure alignment with federal guidelines and reduce audit risks.
PAAS National® is seeing the following common issues when reviewing documents for CMS audits:
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Billing and Filling: Glucagon Emergency Products
Glucagon emergency products are typically low audit risk – when billed correctly. Billing the wrong unit of measure, like “EA” instead of “mL”, is an easy target for auditors to flag. Below is a table to aid in billing the correct unit of measure.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Why Adhering to Your Return to Stock Policy Is So Important
Pharmacies often struggle with patients not picking up prescriptions on a timely basis. The lag time could be caused by several reasons – cost concerns, transportation issues, mental health factors, or miscommunication are just a few of the possibilities. While pharmacies are sympathetic to patient situations, it is prudent to be aware of the consequences for not following a strict return to stock policy.
PBM return to stock policies range from 10 to 30 calendar days. Accordingly, PAAS National® advises pharmacies…
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Interested in a customized FWA/HIPAA Compliance Policy and Procedure program? Contact PAAS National® at info@paasnational.com or (608) 873-1342 to get started today!
Medicare Prescription Drug Coverage and Your Rights (CMS-10147)
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 Part D plan to request a “coverage determination” or prior authorization.
In general, all pharmacies must arrange for this form to be distributed to the patient. While retail pharmacies must provide the notice at point-of-sale, mail order and specialty pharmacies have up to 72 hours to provide it to the patient. Importantly, CMS recognizes the uniqueness of LTC settings and that there is no practical means to deliver the notice directly to the patient; as a result, if the pharmacy can resolve the matter and ensure the LTC patient receives the needed medication or an appropriate substitute, they do not need to deliver the notice. If the matter cannot be resolved, then the pharmacy must deliver the notice within 72 hours to the patient, patient’s representative, prescriber or appropriate staff person at the LTC facility.
The 569 reject will NOT be returned in the following scenarios:
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Proof of Patient Consent for a Refill Request: What You Need to Know
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. PAAS National®’s Proof of Refill Request and Affirmative Response for DMEPOS Items form can be downloaded from the Member Portal.
For non-Part B claims, many PBM provider manuals include language requiring pharmacies to obtain (and retain) proof of member consent prior to delivery. However, enforcement of this requirement is often at the PBM’s discretion (i.e., variable). These policies, at least in part, originate from the 2020 CMS Call letter revisions concerning Part D Mail Order Auto-Ship Modifications. While PBM requests are uncommon, they may ask pharmacies to provide “proof of patient consent to refill” during audits‒ often catching pharmacies off guard. When PAAS National® sees this request, there is typically an underlying reason and it is a seemingly effortless way for the PBMs to recoup claims if the pharmacy does not have the proof. PBM audit algorithms are looking for Fraud, Waste and Abuse conducted by bad actors and will use data analysis as a reason to audit suspicious claims. See the PAAS Tips below for potential reasons why a PBM may ask for proof of refill request upon an audit, and how to ensure compliance of an automatic refill or medication synchronization program.
PAAS Tips:
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
“A” for Abandoned: The Short Life of DAW Code A and What it Means for Multi-Payor Claims
Just 11 short months ago, PAAS National® released the NEW Dispense As Written (DAW) Code Revealed Newsline article about DAW code value “A” (408-D8). DAW A was designed to be utilized on multi-payor claims when one payor required a multi-source brand (or reference biologic with an approved interchangeable biosimilar in the marketplace) and the other payor preferred the generic or interchangeable biosimilar. Today…we bring you news of DAW A’s demise.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
When Precision Fails: The Hidden Issues in Insulin Pen Dosing Calculations
Undoubtedly, a calculator can be found near every data entry and verification station throughout the prescription workflow line. This is, in part, due to PBM requirements that prescriptions have a mathematically calculable set of instructions. Consequently, pharmacies should strive to bill every claim with an appropriate quantity and days’ supply to prevent claim recoupment issues (e.g., overbilled quantity, refill too soon, exceeding plan limitations, etc.). However, there are instances where the pharmacy has the math correct, but the answer is clinically incorrect.
PAAS National® analysts are seeing correct mathematical calculations, but incorrect days’ supply with insulin pens because pharmacies are missing two very important considerations:
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
LTC Essentials: A Guide to Residence Codes, Pharmacy Service Types, and Submission Clarification Codes
With more pharmacies exploring the world of long-term care and LTC Pharmacy at Home dispensing increasing daily, PAAS National® has also been seeing audits on these claims. One area PBMs have been targeting surrounds…
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Combo Shop Pharmacy Inventory Considerations
Independent pharmacies are diving into the long-term care world to improve care for their patients and maximize revenue. Pharmacies can run both retail and combo-shop LTC pharmacies under one roof; typically with the same computer system. However, even though the pharmacies have a single location, the processing of claims and sharing of drug inventory can be challenging.
With a new NCPDP number for the combo-shop LTC, pharmacies will have new wholesaler accounts for ordering medications. Combo-shop LTC locations often have access to lower-cost brands through their LTC agreements. While the two NCPDPs operate in the same location, in many aspects, they need to be treated as two separate “pharmacies”. This raises two key questions that PAAS National® has received from members:
PAAS recommends …
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips: