© Affiliated Computer Services, Inc. (ACS) 2007, 2008

DC PBM Compound Training

June 24, 2009 and June 30, 2009

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Overview

Introductions DC Compound Coverage DC DHCF Payer Specifications Multi-Line Compound Claim Guidelines IV and TPN Compound Submission Paper Claim Compound Submission Compound Reimbursement Questions?

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Introductions

ACS Atlanta Staff Karen Crowley Louise Gustafson Daniel Shackelford, PharmD

ACS DC Staff Wallene Bullard, PharmD Patricia Sims, PharmD

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DC Compound Coverage

Provider Manual

http://www.dcpbm.com

Section 5 - Compounds 5.1 Multi-Line Compound Claim Submission 5.2 IV Compound Submission and Dispensing Fee

Section 6 - Paper Claim (Note: Pharmacies have 181 days from the first Date of Service (DOS) to submit an original claim. The timely filing rules apply to both POS and paper claims.)

Universal Claim Form

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DC DHCF Payer Specifications

7.1 - NCPDP Version 5.1 Payer Sheet Claim Segment (Ø7)

– Field 4Ø6-D6 - Compound Code» Ø = Not specified» 1 = Not a compound» 2 = Compound

– 42Ø-DK - Submission Clarification Code» Ø8 = Process compound for Approved Ingredients » This allows payment for covered ingredients and

ignores non-covered ingredients

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DC DHCF Payer Specifications (cont.)

7.1 - NCPDP Version 5.1 Payer Sheet Compound Segment (1Ø)

– Field 45Ø-EF - Compound Dosage Form Description Code *» Ø3 = Cream» Ø4 = Suppository» 11 = Solution» 12 = Suspension

– 451-EG - Compound Dispensing Unit Form Indicator » 1 = Each» 2 = Grams » 3 = Milliliters

* Some examples only - not inclusive of all valid values

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DC DHCF Payer Specifications (cont.)

7.1 - NCPDP Version 5.1 Payer Sheet Compound Segment (1Ø)

– Field 452-EH - Compound Route of Administration * » 4 = Injection» 7 = Mouth/Throat» 11 = Oral » 17 = Topical

– Field 447-EC - Compound Ingredient Component Count – Field 488-RE - Compound Product ID Qualifier

Ø3 = National Drug Code (NDC) – Field 489-TE - Compound Product ID (NDC)– Field 448-ED - Compound Ingredient Quantity

* Some examples only - not inclusive of all valid values

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Multi-Line Compound Claim Guidelines

Compounds submitted with compound code = 2 must contain more than one ingredient

Multi-line compounds are adjudicated line by line If one or more ingredients are denied, the entire compound

will deny Submit “Submission Clarification Code” = “Ø8” to allow

processing of covered ingredients To request PA of non-covered ingredients, contact Help Desk

at (800) 273-4962 or fax PA form to (866) 535-7622 Compounds exceeding $125.00 require UCF submission

© Affiliated Computer Services, Inc. (ACS) 2008Slide 9

IV and TPN Compound Submission

IV compound claims are determined by submitting a medication with an IV route of administration

All IV compounds require prior authorization for submission (POS and Paper)

Without PA claims will reject with NCPDP Reject Code 70 – Product/Service Not Covered

Compounds containing an ingredient in Therapeutic Class C5B are classified as TPN claims

© Affiliated Computer Services, Inc. (ACS) 2008Slide 10

Compound Reimbursement

Compound TypeIngredient Cost

(Each Line Item Calculated Separately)

Dispensing Fee(For Entire Compound)

ALL Compounds (excluding IV and TPN)

Lesser of Submitted Ingredient Cost or District Allowed Amount or FMAC

$4.50

IV Lesser of Submitted Ingredient Cost or District Allowed Amount or FMAC

$7.25

TPN Lesser of Submitted Ingredient Cost or District Allowed Cost or FMAC

$17.25

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Paper Claim Compound Submission

When submitting paper claim forms, DC DHCF requires the use of the NCPDP Standard Universal Claim form.

Paper claims are required for compound claims over $125.00.

Paper Claims should be sent to the ACS Call Center at the address below:

ACSP.O. Box 967Henderson, NC 27536Attn: Paper Claims Processing

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Sample Compound Claims

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Sample Compound Claims

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Sample Compound Claims

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Questions?