Prime Recovering Claims on Drug Substitutions

PAAS has seen Prime Therapeutics recover claims for the following reasons:

  1. FCD: “The pharmacy has submitted this claim or series of claims multiple times using a different drug throughout the claim submission.”
  2. FCR: “The pharmacy has submitted this claim or series of claims incorrectly. If submitted correctly, this claim, or series of claims would have rejected and required a prior authorization review.”
  3. FCP: Prior Authorization – “The pharmacy has submitted this claim or series of claims inappropriately in order to obtain an approved prior authorization.”

Inappropriate Billing Practices are discussed in the Prime Provider Manual, Section 2 and Unacceptable Billing Practices are found in Section 6. Here are a few examples:

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  • Inappropriate application of therapeutic interchange protocols – A participating pharmacy dispensing a different covered medication than prescribed without obtaining and documenting the Prescriber’s consent prior to dispensing and without informing the Covered Person of the substitution
  • Phishing to identify a drug that is covered (i.e., a Participating Pharmacy submits a claim for one drug, receives a reject or reverses the claim and then resubmits for a new drug within a short period of time)
  • Billing high cost products when lower cost alternative products are available
  • Billing for drugs that the Prescriber did not order
  • Billing for drugs where the Covered person and the Prescriber do not have a valid patient-prescriber relationship
  • Billing for drugs where the Pharmacy does not have a valid prescription order
  • Billing for a therapeutic interchange medication without contacting the Prescriber before the claim is submitted to confirm the interchange
  • Billing for prescriptions during posted business hours when the Pharmacy is not physically open
  • Billing for prescriptions in order to bypass the POS edits or messaging

PAAS Tips:

  • Do not bill test claims – always bill pursuant to an actual prescription. Should a patient request their prescription back, make sure to retain a copy for your records.
  • Do not bill a claim for a drug that has not been authorized by the physician
  • Always follow POS reject messages – do not bypass plan limits or prior authorization requests, including changing quantity, days’ supply, or price
  • If the prescriber is authorizing a change in the medication, it is ideal (for their corresponding records and yours) to have the prescriber send a new prescription to the pharmacy
  • Review the Prime Provider Manual for best billing practices and the discrepancy code table
  • PAAS National® recommends against the use of template or pre-printed prescription forms with broad substitution protocols or cascades. See May 2019 Newsline article Pre-Printed Prescription Forms Put You at Risk.