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Avatar Setup

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Describes the standards and settings necessary for NCPDP billing within myAvatar .

System Requirements

  • RxConnect - Standard Internet Explorer 11, is required. RxConnect Version 6.3 or higher is required for NCPDP.
  • myAvatar Order Entry version 2018
  • myAvatar PM version 2018 up to Update #30
  • myAvatar HL7 Module version 2018
  • myAvatar RADplus versions 2011 or higher are supported. Should be on current version of RADplus.
  • Cache 2010 is supported.

► Registry Settings

  • Enable NCPDP Billing
  • Enable NCPDP Eligibility Verification Request
  • Maximum Eventual Order Duration Controlled Substances
  • Maximum Eventual Order Duration Apply to NCPDP 
  • Enable 'Additional Drug Information' Fields
  • Allow Roll-Up Rule Selection During Compile
  • Enable Roll-Up Date Range Definition
  • Default Write Off Posting Code

Default Settings for Processing an Inbound HL7 Charge Batch

The Default Settings for Processing an Inbound HL7 Charge Batch form needs to be configured for Pharmacy Service Charge Type. This is necessary to define a facility for NCPDP billing when processing charges coming in via HL7 from RxConnect to myAvatar .

Default Settings for Processing an Inbound HL7 Charge Batch Section
  • Charge Type - Select Pharmacy.
  • Auto-Create Service Codes - This setting will enable the Auto-Create Service Code section to this form. The Auto-Create Service Code section allows a facility to define the default values of a service code that will be created when new RxConnect Charge Codes are sent to myAvatar via the HL7 Inbound Charge Process. The Charge Batch Report generated at the time of Compiling HL7 Charges will display a new sub-report for viewing any newly added myAvatar service codes.
  • Is NCPDP Billing Done At This Facility: Determines whether or not the system should be enabled for NCPDP billing rules. Facilities billing Medicare Part D using NCPDP may not perform a roll-up during compile. If set to Yes, additional fields are populated automatically.
  • Add Surcharge To Each Line Item: If Is NCPDP Billing Done at this Facility? is set to Yes, this field will be set to No and disabled. A surcharge amount for NCPDP charges can be specified in the NCPDP System Defaults form.
  • Match On Order Number When Applying Credits: Indicates whether or not credits should be applied according to order number. If Is NCPDP Billing Done at this Facility? is set to Yes, this field will be set to Yes and disabled, as this is necessary for NCPDP billing.
  • Match On Which Date When Applying Credits: Indicates how credits are applied according to transaction date. If Is NCPDP Billing Done at this Facility? is set to Yes, this field will be set to Any Transaction Date but can be edited.
  • Post Credits Against The Client Ledger: Indicates whether or not credits are posted in the client ledger.  Credits will be applied to charges on the client ledger if the charge itself has not yet been included in a roll-up.
  • Perform A Service Roll-Up: Indicates whether or not services will be rolled up according to episode, service code, order number and NDC. This functionality is not available for NCPDP billing. If Is NCPDP Billing Done at this Facility? is set to Yes, this field will be set to No and disabled, as this functionality is not available for NCPDP billing.
Auto-Create Service Codes Section
  • Service Required By: Set as Both to file the service against a client and physician. 
  • Type of Service: Set to Individual to support creating individual service codes. 
  • Type of Fee: Recommendation is to set to Fixed Fee (Per Event). The recommended process is to receive the charge fee from RxConnect and that it’s not calculated by Minutes per Unit. 
  • Minutes per Unit: Recommendation is to set service codes per Fixed Fee, therefore, this is not needed. 
  • Designated Degree of Rounding: Recommendation is to set service codes per Fixed Fee, therefore, this is not needed. 
  • Group Code: Define the appropriate default group code to define for the services that will be created. 
  • Insurance Charge Category: Define the appropriate default insurance charge category for the services that will be created.
  • Does this Code have a Professional Component: Set to No.
  • Is this a Pharmacy Service: Set to Yes.
     

NCPDP System Defaults

The NCPDP System Defaults form allows you to define default settings for NCPDP Claims Processing.

 

Sub System Code Functionality

The Sub System Code functionality will support defining a Facility ID to be used to match to the correct RxConnect hospital.

The following registry setting will introduce the Facility ID field on this form. You can then use the By System Code Facility section in the NCPDP System Defaults form to define the Pharmacy NPI, CMS Part D Qualified Facility and Prescription Origin code on the Sub System Code level.

  • Enable RxConnect Facility ID - Registry Setting Value: ‘Y’

 

Guarantors/Payors

 New fields required for NCPDP billing on the Guarantors/Payors form include:

  • BIN Number - Enter the BIN number used to identify the processor of the claim and correctly route the claim.
  • Processor Control Number - Enter the processor control number used to route the claim within the processor's system. This number is assigned by the processor.
  • Plan ID - The plan ID is normally defined within the NCPDP Defaults form and so should only be valued here if a different value is needed per guarantor. 
  • Vendor Certification ID - Enter the vendor ID number used to identity DayTech CE2000, and the certified source of the transaction.

 

 Avatar PM Dictionary Setup

  1. The Financial Class dictionary needs to have the extended dictionary System Financial Class (1500) defined. Select NCPDP-Medicare Part D to define the guarantor associated with the financial class as a Medicare Part D NCPDP guarantor. The selection NCPDP-Other will support future functionality to allow billing on NCPDP format for other Non-Medicare Part D payors.
  2. The Treatment Setting dictionary needs to have the extended dictionary NCPDP Pharmacy Service Type (10500) defined.
    • 50: Treatment Setting
              I = Inpatient/Residential
              NCPDP Pharmacy Service Type: Institutional Pharmacy Services
              O = Outpatient
              NCPDP Pharmacy Service Type: Long Term Care Pharmacy Services
              P = Partial Hospitalization
  3. The Client's Relationship to Subscriber dictionary needs to have the extended dictionary NCPDP Patient Relationship Code (10249) defined.
    • 1 = Self
            NCPDP Patient Relationship Code: Cardholder
  4. The Location dictionary needs to have the extended dictionary NCPDP Patient Residence Code (7011) defined for programs being used for clients who have Medicare Part D guarantors.
    • Choose the code for Inpatient Hospital or its equivalent.
          NCPDP Patient Residence Code: Nursing Facility

myAvatar Order Entry Dictionary Setup

  • The Order Type dictionary has an extended attribute called Maximum Eventual Order Duration (525) that should be defined for the appropriate order type. This setting will indicate the maximum number of days we allow for an order duration. It is recommended to set this value to "365" for the Pharmacy (medication) order types. You may not create or change orders to have a duration exceeding the value entered in this extended dictionary. For non-controlled substances, a value of "365" is recommended in order to follow the standard industry rule that non-controlled substances not exceed a year. A comparison is made between the values entered within the Maximum Eventual Order Duration For Controlled Substances registry setting. myAvatar will utilize the lesser value of either the extended attribute or the value defined by DEA Class.
  • The Order Category dictionary has two extended attributes that can be set:
    • Maximum Value Allowed for # of Refills Allowed (20354)
    • Maximum Value Allowed for 'Expected Days Supply' (20353)

The intended use is to allow you to define a maximum amount for Leave and Discharge orders. For example, if the Maximum Value Allowed for Expected Days Supply extended attribute is "15" for Leave orders and you enter "20" for the Expected Days Supply, an error message would indicate the "Expected Days Supply cannot be greater than 15 for Leave orders."

Recommendation: For take home discharge orders, the maximum days supply should not exceed seven.

Service Code Setup

There needs to be a one-to-one relationship between charge codes in RxConnect and service Ccdes for pharmacy items in myAvatar . The Drug Master may be exported from RxConnect and used to create a Service Code Upload file for myAvatar . In addition, myAvatar supports the ability to auto-create the service codes when they are received in the HL7 queue and ready to be compiled and posted. That process ensures that any newly-added charge codes will automatically get created in myAvatar in order to process and post the charge. For faster processing, charge codes should be set up during implementation. 

The following fields must be defined:

  • NCPDP Unit of Measure - Provides the default value if the Unit of Measure is NOT provided by the pharmacy. This information is provided by RxConnect. This is only enabled for services where the field Is This A Pharmacy Service is set to Yes.
  • Is This A Pharmacy Service - Select Yes to designate those service codes that could be billed using the NCPDP format.
  • Service codes are to be set up as:
    • Service is Required By = Both - Require client and practitioner
    • Type of Service = Individual
    • Type of Fee = User Defined - User Based
    • Minutes per Unit = 1 minute (1 minute = 1 pill)
    • Unit Rounding Logic = NO rounding
    • Designated Degree of Rounding = Whole Unit
    • Group Code = Pharmacy
    • Insurance Charge Category = Pharmacy or OTC
    • Is This a Balance Forward Service Code? = No, as the default
    • Does This Code Have a Professional Component? = No, as the default.
    • Is This Service a Visit? =  No, as the default.
    • Is This a Pharmacy Service? = Yes

National Drug Code, Drug Quantity, and Unit or Basis of Measurement are overrides. The values are sent from RxConnect to myAvatar PM as part of the HL7 message. These fields will override values sent from RxConnect if populated.