Carry Clinical Notes Forward for Audit Coverage

For example, pharmacies may opt to forego billing for generic attention-deficit/hyperactivity disorder (ADHD) medication knowing that a longtime pharmacy customer’s insurance requires brand. A clinical note stating “insurance requires brand” or producing proof of the generic being rejected on a prior adjudication would still be needed to substantiate billing the DAW 9. For the instances where a DAW 2 is used (“Substitution Allowed – Patient Requests Product Dispensed”), those clinical notes need to be included on each prescription as well, or else there is risk that the PBM will look to recoup the claim.

When DUR rejects occur, especially for Express Scripts, showing what steps were taken to give due diligence to the reject is required, such as contacting the prescriber to ensure they were aware of a potentially harmful drug-drug interaction. Pharmacies may opt to not call every month on the same DUR reject and therefore notation of the last time the DUR was addressed is necessary. This brings up the question of how often to rechallenge billing the generic medication or to reconfirm the clinical note with the prescriber. There is not a steadfast rule; however, it is our guidance that pharmacies rechallenge with each new prescription, apart from C-II medications, medication dosage changes, and the beginning of each plan year.

PAAS Tips:

• Proper Clinical Notes include the following information:
  • Date
  • Name and title of individual providing information
  • Specific information provided
  • Pharmacy staff initials
• DAW codes are also applicable with biologic products. Refer to DAW Codes Explained and Billing Guidance: When to Use DAW 0 vs. DAW 9 to ensure proper DAW billing practices.