Seasoned pharmacy staff can often list off the patients who prefer brand drug or whose insurance requires the brand name for certain medications. Some pharmacy staff know their customers so well that they know exactly how to adjudicate a claim without receiving any rejects. In fact, that is one of the many benefits of independent pharmacy – the high-level of personalized experience customers receive. However, issues arise when an auditor, who has no prior knowledge about your patients, reviews hardcopies as part of an audit and does not see supporting documentation to substantiate how the claim was adjudicated. That is why it is of the utmost importance that…
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.
- Proper Clinical Notes include the following information:
- 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.