Class

1
Welcome to Class 319 ePharmacy - Advanced
(Million Dollar Baby) VEHU 2007
2
ePharmacy Faculty

• Greg Laird
• Judy Petersen
• Janet Graham

3
ePharmacy Objectives

• By the end of todays session youll be able to
• Understand how ePharmacy processes CMOP and Local
  Mail Out transactions
• Realize the importance of ePharmacy messages
• Be aware of the OPECC ECME User Screen
• Recognize the significance of the ePharmacy
  parameters and reports
• Know how to find ePharmacy resources

4
Overview
5
e-Pharmacy Overview

• e-Pharmacy is the real-time processing of
  electronic prescription claims from VistA to
  Third Party Payers
• Electronic processing of third party claims is a
  HIPAA requirement
• ePharmacy transactions only take place when
  Veteran has Prescription Insurance and Rx is
  billable
• Payers provide an immediate adjudicated response
• Claim is marked payable or rejected
• Average response time 18 seconds

6
e-Pharmacy Overview

• Staff Pharmacists resolve Drug Utilization Review
  (DUR) or Refill Too Soon (RTS) rejects
• ePharmacy claims for CMOP and Local Mail Outs
  processed as part of background job
• DUR RTS rejects from this process are sent to
  Third Party Payer Rejects - Worklist for
  resolution by ePharmacy Site Manager
• Revenue Staff responsible for resolving all other
  rejects
• Insurance Verifiers responsible for maintaining
  Veteran insurance information

7
ePharmacy - Under the Hood

• Processing Window Fills

8
Processing Window Fills
9
Window Fill - Payable
10
Window Fill - PayableRx Label Prints
11
Window Fills Transmission
12
Window Fill RejectedReason Invalid Ins, NDC,
Days Supply, etc.
13
Window Fill RejectedReject to OPECC / Rx Label
Prints
14
Window Fills Transmission
15
Window Fill RejectedReason Refill Too soon
or DUR
16
Window Fill Rejected Reject to Users screen /
NO Rx Label Prints
17
Window Fill Rejected Reject resolved / Rx
Label Prints
18
ePharmacy - Under the Hood

• Processing CMOP Fills

19
CMOP Transmissions

• Before e-Pharmacy Activated

20
CMOP Transmission Processbefore e-Pharmacy
21
Prescriptions transmitted to CMOP
22
CMOP Transmissions

• After e-Pharmacy Activated

23
e-Pharmacy Steps added to CMOP Transmission
process
24
e-Pharmacy evaluation occurs on Prescriptions
25
Payers adjudicate e-Pharmacy claims
26
Wait Time built in to process
27
Prescription 1 is Non-BillableRx sent to CMOP
28
Prescription 2 is PayableRx sent to CMOP
29
Prescription 3 Non-Billable (Null DEA)Rx sent
to CMOP
30
Prescription 4 No Payer Responsee-mail sent to
Key holders / Rx kept in CMOP queue
31
Prescription 5 Rejected Invalid NDCReject
sent to OPECC / Rx sent to CMOP
32
Prescription 6 Rejected Refill Too SoonReject
sent to Third Party Reject Worklist
33
Recap Status of Six Prescriptions
34
CMOP Transmission Today 1
35
CMOP Transmission Today 1
36
CMOP Transmission Today 2
37
CMOP Transmission Today 3
38
NDC Change - CMOP

• Rx Activity Log Jul 26, 2007_at_125419
  Page 4 of 6 ECME, Patient One PID
  -- Ht(cm) 175.26
  (03/14/2007) DOB
  Wt(kg) 67.91
• ECME Log
  Date/Time
  Rx Ref Initiator Of Activity
  
  1
  6/25/07_at_191806 REFILL 3 RPH,ONE P
  Comments Submitted to
  ECMECMOP TRANSMISSION(NDC00006-0072-31)
  2 6/25/07_at_222134 REFILL 3
  POSTMASTER Comments
  Submitted to ECMECMOP RELEASE(NDC00378-3151-93)
  
• Enter ?? for more actions
  Select ActionNext Screen//

39
Final Recap Six Prescriptions
40
Local Mail

• Local Mail Label Print before ePharmacy
• Local Mail Label Print after ePharmacy
• 1st Step
• Wait Time
• 2nd Step

41
Local Mail Label Printbefore e-Pharmacy
42
Local Mail Label Printafter e-Pharmacy 1st step
43
Local Mail Label Print - Wait Time
44
Prescription 1 is Non-BillableRx sent to Label
Printer
45
Prescription 2 is PayableRx sent to Label
Printer
46
Prescription 3 Non-Billable (Null DEA)Rx sent
to Label Printer
47
Prescription 4 No Payer ResponseNo e-mail sent
/ Rx kept in Suspense queue
48
Prescription 5 Rejected Invalid NDCReject
sent to OPECC / Rx Label prints
49
Prescription 6 Rejected Refill Too SoonReject
sent to Third Party Reject Worklist
50
Recap Six Local Mail Prescriptions
51
Pull from Suspense Today 1
52
Process RTS Reject Today 1
53
Process DUR Reject Today 1
54
Pull from Suspense Today 2
55
Pull from Suspense Today 3
56
Final Recap Six Local Mail Rxs
57
ECME User Screen
58
ECME User Screen
Select ECME Option U ECME User Screen
MGR Pharmacy ECME Manager Menu ... RPT
Pharmacy Electronic Claims Reports ... Select
ECME Option U ECME User Screen Please wait...
59
ECME User Screen

• PHARMACY ECME Jun 05, 2007_at_141512
  Page 1 of 6
• SELECTED DIVISION(S) ALL
• Transmitted by ALL users Activity Date
  Range within the past 7 day(s)
• 
  Sorted by Insurance
• PATIENT/DRUG/COMMENTS INSURANCE/NDC/RX/ECM
  E LOC/TYP RXINF
• 1 ONE,ECME PATIENT (XXXX) AETNA PH/800
  238-6279 Done Pb0 Rj6 AcRv0 RjRv0
• 1.1 HYDROCHLOROTHIAZIDE 50 65243-0040-09
  51413205C 3/9631034 C RT ACT/RL
• Rejected
  
• 54Non-Matched Product/Service ID Number
  
• To dispute this claim, call 1-800-238-6279
  for forms and instructions
• 1.2 OMEPRAZOLE 20MG SA CAP 62175-0118-43
  51513913A 3/9631038 C RT ACT/RL
• Rejected
  
• 70Product/Service Not Covered
  
• RX not covered- consider Prilosec OTC. To
  dispute this claim, call 1-800-2
• 38-6279 for forms and instructions
  
• 1.3 SIMVASTATIN 40MG TAB 00006-0749-82
  51399898C 3/9631040 C RT ACT/RL
• Rejected
  
• 76Plan Limitations Exceeded
  
• Enter ?? for more actions

60
ECME User Screen Sort List

• CU Continuous Update REV Reverse Payable Claim
  FR Further Research
• UD Display Update RES Resubmit Claim
  PD Print Data
• CV Change View CLO Close Rejected Claim
  LOG Print Claim Log
• SO Sort List CMT Add/View Comments
  EX Exit
• Select Action Next Screen//SO Sort List
• Select one of the following
• T TRANSACTION DATE
• D DIVISION
• I INSURANCE
• C REJECT CODE
• P PATIENT NAME
• N DRUG NAME
• B BILL TYPE (BB/RT)
• L FILL LOCATION
• R RELEASED/NON-RELEASED
• A ACTIVE/DISCONTINUED

61
ECME User Screen

• PHARMACY ECME Jun 05,
  2007_at_150636 Page 1 of 7
• SELECTED DIVISION(S) ECME DIVISION
• Transmitted by ALL users Activity Date
  Range within the past 5 day(s)
• 
  Sorted by Reject Code
• PATIENT/DRUG/COMMENTS
  INSURANCE/NDC/RX/ECME LOC/TYP RXINF
• ---- Reject code 19M/I Days Supply
  ------------------------------------------
• 1 ECME, PATIENT ONE (YYYY) CAREMARK/800
  345-5413 Done Pb0 Rj2 AcRv0 RjRv0
• 1.1 MINOCYCLINE HCL 50MG C 00093-3165-01
  51293352C 3/9555018 C RT EXP/RL
• Rejected
  
• 76Plan Limitations Exceeded
  
• 19M/I Days Supply
  
• Maximum Days Supply of 60 RX
  IS OVER ONE YEAR OLD
• 1.2 LEVOTHYROXINE NA (SYNT 00074-9296-19
  51293349C 3/9558187 C RT ACT/RL
• Rejected
  
• 76Plan Limitations Exceeded
  
• 19M/I Days Supply
  
• Maximum Days Supply of 60
  
• 2 ECME, PATIENT TWO (ZZZZ) AETNA PH/800
  238-6279 Done Pb0 Rj4 AcRv0 RjRv0

62
Parameters, Bulletins and Reports
63
Auto Reversal Process

• It is critical to release all billable
  prescriptions filled in a timely manner
• Otherwise VA may receive payments for
  prescriptions never filled
• ECME Auto Reverse Parameter defines the number of
  days the system will wait before the ePharmacy
  sends a reversal transaction to the payer
• Exceptions
• Prescriptions filled as given in clinic should
  not be released.
• The ECME Auto reversal should occur on these Rxs
  since we should not bill the third party for
  these medications.
• ECME Auto Reverse process reverses claims for
  outpatient prescriptions processed for inpatients
• (example self-medication programs)

64
ECME Parameters

• ECME Parameters
• Auto-reverse parameter
• Can be set for 0-30 days
• Most sites set at 4 days
• Work with OPECC and Accounts Receivable staff to
  determine best setting
• ECME Timeout
• Has to do with the number of seconds
  transmissions will go on before user is allowed
  to go to next task
• Can be set for 0-30 seconds
• Most sites set at 30 seconds

65
Through Days and Pull Ahead Settings

• Pharmacy parameters control when Rxs sent to
  CMOP
• CMOP Thru Days CS Transmission
• CMOP Thru Days Non-CS Transmission
• Days to Pull Suspended CS CMOP
• Days to Pull from Suspense

66
CMOP Thru Days Parameters

• CMOP Thru Days CS Transmission
• CMOP Thru Days Non-CS Transmission
• Daily process identifies all Prescriptions in the
  Suspense file with Fill dates that fall within X
  days in the future for transmission to CMOP.
• Parameters allow time for prescriptions to be
  transmitted, processed and mailed to a patient.
• Each can be set for 0 to 10 days

67
Outpatient Days to Pull Parameters

• Days to Pull Suspended CS CMOP
• Days to Pull from Suspense
• Used to find additional prescriptions for the
  patients identified by the CMOP Thru Days
  process. The purpose is to help minimize mailing
  costs.
• Each can be set for 0-10 days

Example Patient One has 3 prescriptions
identified by the CMOP Thru Days process. The
system now looks to see if Patient One has
additional prescription will Fill Dates X days in
the future to add to the CMOP Transmission. (X
the divisions Days to Pull number)
68
Why are these parameters important?

• The pull ahead parameters have an impact on the
  Date of Service used on an e-Pharmacy claim.
• We dont recommend changing your parameters
  initially
• Remember, e-Pharmacy prescriptions will be a
  small percentage of your total suspended
  prescription volume.
• Changing parameter sessions can be considered if
  you see a significant number of RTS rejects

69
Pull Ahead Settings at Six ePharmacy Sites
70
ePharmacy Bulletins
71
CMOP Not Transmitted Message

• Subj ePharmacy - CMOP Not TRANSMITTED Rx List
  55657173 07/24/07_at_1844
• 15 lines
• From POSTMASTER In 'IN' basket. Page 1 New
• --------------------------------------------------
  ------------------------
• The prescriptions listed below are third party
  electronically billable.
• They have not been transmitted to CMOP because
  they have been submitted to
• third party payer but we have not received a
  response regarding these
• prescriptions yet. The prescriptions will remain
  in the CMOP queue to be
• transmitted in the next transmission if the
  response from the third party
• payer has been received.
• Division ECME TEST
• --------------------------------------------------
  -----------------------------
• RX/Fill PATIENT(LAST4SSN) DRUG
  FILL DATE
• --------------------------------------------------
  -----------------------------
• 52593020A/0 ECMEpatient,One(0000) FORMOTEROL
  FUMARATE 12MCG Jul 29, 2007
• Total ECME TEST 1 Patients and 1 Prescriptions.

Bulletin sent to users who hold the PSXMAIL
security key.
72
Auto-Reversal e-Mail Message

• Subj ECME AUTO-REVERSAL PROCESS 55682790
  07/09/07_at_0100 12 lines
• From BPS PACKAGE In 'IN' basket. Page 1
  New
• --------------------------------------------------
  -------------------------
• The ECME Nightly Process completed auto-reversals
  for the following e-Pharmacy prescriptions.
• TOTAL AUTO-REVERSED CLAIMS 3
• Claims Auto-Reversed on 07/09/06
• RX FILL STATUS FILL DATE PATIENT
  BPS PHARMACY
• --------------------------------------------------
  -------------------------
• 1 987654321 1 W/RL 07/03/07 TEST,PATIENT
  ONE ECME 2 TEST
• 2 123456789C 2 C/NR 07/14/07 TEST,PATIENT
  TWO ECME TEST
• 3 787878787 1 M/RL 07/03/07 TEST,PATIENT
  THREE ECME 2 TEST
• --------------------------------------------------
  -------------------------
• Enter message action (in IN basket) Delete//

Bulletin sent to members of the G.BPS OPECC mail
group
73
RX Not Processed
Subj RX not processed for site ECME TEST VAMC
4757272 07/01/07_at_1253 11 lines From BPS
PACKAGE In 'ECME' basket. Automatic Deletion
Date Aug 30, 2007 Page 1 New -----------------
--------------------------------------------------
----------- Prescription 4150294 and fill number
0 could not be processed because the previous
request was in progress. There may have been a
delay in processing of the previous claim or the
previous claim may be stranded. For more
information on this prescription's activity,
please view the ECME log within the View
Prescription (VP) option on the Further Research
(FR) menu of the ECME user screen. Patient
Name ECMEpatient,One Last four digits of SSN
0000
Bulletin sent to members of the G.BPS OPECC mail
group
74
ePharmacy Reports
75
Claims Submitted, Not Yet Released Report

• 
  
• Electronic Claims Management
  Engine (ECME) V1.0
• ECME TEST DIV
  
• Claim Results and
  Status
• 
  
• PAY Payable Claims Report
• REJ Rejected Claims Report
• ECMP CMOP/ECME Activity Report
• REV Reversal Claims Report
• NYR Claims Submitted, Not Yet Released
• REC Recent Transactions
• DAY Totals by Date
• CLO Closed Claims Report

76
Results of Not Yet Released Rx Report

• DIVISION PATIENT NAME RX DATE DRUG FILL
  LOCATION
• ECME TE ECME,ONE PATI 564477 6/30/07
  CITALAPRAM 20MG M
• ECME TE ECME,TWO PATI 564544 7/01/07
  OXYCODONE 10MG W
• ECME TE ECME,THREE PA 564621 7/02/07
  DIGOXIN 0.2MG C
• Other fields, including insurance and
  reimbursement information, can be printed on this
  report.

77
ePharmacy Automation
78
Automation/OPAI Lessons

• HL7 Complete Message
• Does it exist for the Rx?
• Is the RXD segment correct?
• NDC
• Does the vendor system return the actual NDC?
• Is it an 11-digit number?
• File 52
• Rx released (auto or manual) vs unreleased
• Field 27 (for Original)
• Field 52, Subfield 11 (for Refills)
• Vendor Dispensing Reports

79
McKesson/Parata Automation

• Working with test sites
• Testing OPAI with McKesson/Parata
• Test ePharmacy with McKesson/Parata OPAI

80
ePharmacy Challenges Resources
81
Challenges

• Days Supply Rejects
• 90 day fills main issue
• More payers are accepting now
• Invalid NDC rejects
• Main problem is with re-packagers NDCs not being
  recognized by third parties
• Problems getting Data Management company (First
  Databank Medispan etc.) files updated for NDC
• Much progress has been made
• Dispensing units a problem
• Third parties want insulin quantities expressed
  in ml and inhalers in gms - VA uses unit of
  each
• Temporary fix currently being tested

82
Challenges (continued)

• Billing Tricare and ChampVA
• These claims use a cost plus fee billing
  structure
• VA will not dispense Rx if claim not payable
• Working on requirements for a future enhancement
• Patient inquiries and concerns
• Patients know their copays are reduced by monies
  collected from third party
• Third Parties send EOBs to the patient providing
  the status of the claim, e.g., Invalid NDC
• Patient may have to make a VA copayment when
  they previously did not have to when a paper
  claim was submitted for the same drug
• Patients sometimes call Pharmacy about third
  party processing questions

83
Educational Resources

• ePharmacy User Support Calls VANTS 82429
• 2nd 4th Monday of each month _at_ 11 am Eastern
• VistA University ePharmacy Training Page
• http//vaww.vistau.med.va.gov/VistaU/e-bp/e-pharma
  cy.htm
• Live Meeting Sessions
• e-Pharmacy Checklists
• Show-Me videos
• ePharmacy Simulation Training located on VA
  Employee Education System On-Line Learning
  Website
• https//vaww.ees.aac.va.gov/librix/loginhtml.asp?v
  librix
• OIT Project Website
• http//tspr.vista.med.va.gov/warboard/anotebk.asp?
  proj699TypeActive
• VISN POCs

84
Questions?