What to Do (and Not Do) When Your Days’ Supply is Rejected

The first step is to make note of any reject messages received when processing for the correct days’ supply. For example, if the insurance limits the quantity to a 30 days’ supply, write “ILQ 30” on the prescription. Then reduce the quantity, if possible, and rebill the claim with the adjusted [accurate] days’ supply based on the revised quantity. Reduce the quantity further if the claim still rejects, until you reach the smallest unbreakable package size.

If the smallest unbreakable package size still does not go through with an accurate day’s supply:

1. PBMs may provide claim reject messaging to prompt submission of “SCC 10” to allow the true day supply for accurate refill intervals, reimbursement and copays. Document use of this on the prescription.
2. Call the PBM helpdesk and request an override – document on the prescription if approved or denied.
3. If no smaller package size exists and PBM can’t (or won’t) issue an override, most PBMs will allow the smallest package to be billed for the maximum days’ supply identified in the original reject message.

If the above process is used, and you processed the claim with an adjusted [inaccurate] days’ supply, you are at risk for early refills because the PBM adjudication logic will allow you to submit a refill claim when the utilization threshold is met based on the previous days’ supply adjudicated, not the actual days’ supply. PBMs still require the pharmacy to monitor utilization and only refill when appropriate based off the accurate [calculated] days’ supply and not the adjudicated days’ supply. Remember, the claim rejection for “refill too soon” will not be appropriately triggered when the pharmacy is forced to bill a smaller days’ supply than the true calculated day’s supply. To help avoid this, PAAS National^® suggests documenting the actual days’ supply in the directions for use (e.g., “actual days’ supply=37”) so that it prints on the label to alert staff and patients of the appropriate refill intervals.

Another situation pharmacies run into is when the accurate days’ supply is rejected due to exceeding the plan limit for a maximum daily dose.

For example, a prescription written for OxyContin^® 30 mg, quantity 90, with directions to “take one tablet 3x daily” may receive a rejection for “Maximum two tablets per day.”

In this situation, pharmacies should not reduce the quantity to 60 tablets for a 30-day supply (this would be considered bypassing the plan limit). Instead, pharmacies should pay close attention to any messages given on how to resolve the rejection, including calling the PBM help desk for an override or getting a prior authorization started with the prescriber. Alternatively, the prescriber could decide to change the dose or prescribe an alternative medication.

What if the prescriber refuses to obtain a prior authorization or change the prescription to a clinically appropriate dose? Can the claim be split-billed? PAAS National^® highly recommends against split billing or processing a claim as cash to circumvent a plan limit or prior authorization requirement. A doctor who refuses to obtain a prior authorization or change the medication/dose could be a red flag for diversion with controlled substances. Most plan limits are put in place based on appropriate clinical use and bypassing them can lead to easy recoupments for PBMs. Pharmacists have a corresponding responsibility to ensure that prescriptions are for legitimate medical purposes, especially for controlled substances.

PAAS Tips:

• Always bill an accurate days’ supply based on the directions first; many PBMS have overrides in place for the smallest package sizes
• Only follow the ILQ process above if you are dispensing the smallest unbreakable package size
• Billing a 30-day supply on two boxes of insulin that should last 50 days is not appropriate. Instead, you must resubmit one box for 25 days if the plan limit is 30 days
• Include a notation on the patient label to help notify patients and pharmacy staff of the true days’ supply
• Check with your software vendor to see if additional days’ supply fields are available for internal tracking
• Avoid med sync or cycle fill programs for products whose correct days’ supply cannot be submitted for the smallest single package size
• Educate all pharmacy staff to identify rejection messages and how to properly resolve them
• Any DUR verifications, especially if using “M0” (prescriber consulted) to override the DUR, should have supporting documentation on the prescription or within retrievable electronic records
• Do not split bill rejected claims
• Charging the patient cash often leads to complaints [from the patient to an employer or PBM] and can be considered non-compliance with the provider manual and lead to remediation, including potential network termination
• If you have exhausted all plan options (including pursuing PAs and/or alternative therapies) and the patient insists on paying cash for the full prescription, be sure that you document authorization from the patient that they desire to pay the full cost and will not seek reimbursement from the insurance.
•  Review our Can You Bill It As 30 Days? document under Proactive Tips on the Member Portal