Electronic Re-Billing Service Assignment - NCPDP
After DayTech transmits the converted NCPDP bill, the NCPDP response file are read into myAvatar automatically, and stored within SQL tables for reporting. Once read, the response files are deleted. An 835 electronic remittance is sent by the payer to complete the billing process.
Response File Processing Details
- The claim response file data is stored in two Cache tables. One contains the file header information (SYSTEM.billing_med_d_resp_hdr) and another contains the individual claim response records (SYSTEM.billing_med_d_resp_dtl).
NCPDP Re-Billing Service Assignment Section
The following sections of the Electronic Re-Billing Service Assignment form are used for NCPDP billing.
Overview
Review NCPDP response data and enter 'DUR Overrride' codes and 'Submission Clarification' codes that are filed with the re-bill information. You can also flag response data to be sent to RxConnect to obtain the pharmacist's DUR and/or submission clarification codes.
Before You Begin
- An electronic bill must be claimed in the Electronic Billing form.
Steps
- In the Client ID field, enter the client name, and select.
- In the Add/Delete field:
- Select Add Claim To Re-Bill to assign services that have been claimed to for re-billing.
- Select Delete Claim From Re-Bill to remove a service from a re-billed claim.
- In the Claim Number field, select the claim number.
- In the Select Service for Re-Billing field, select the service.
- The NCPDP Response button launches a screen that displays the service details.
- Click DUR Overrides. The Enter Overrides screen displays.
Select values for the following fields:
- Reason for Service Code
- Professional Service Code
- Result of Service Code
- DUR/PPS Level of Effort
- DUR Co-Agent ID Qualifier
- DUR Co-Agent ID
- In the Submission Clarification field, select the items that clarify the reason for re-billing.
- In the Transaction Type field:
- Select Claim Billing (B1) when a denial has been received with no associated payment for the claim. This is a B1 Transaction form.
- Select Claim Reversal (B2) when a payment has been received for a claim and needs to be reversed. This is a B2 Transaction form.
- Select Claim Rebilling (B3) when a claim has been sent but needs to be adjusted. This is a B3 Transaction form.
- The guarantor must be set up for rebilling via the Payors That Support Rebilling (B3) field on the NCPDP System Defaults form.
- In the Mark as Resolved upon Filing field:
- Select Yes to have all of the records marked as Resolved upon submission.
- Select No to have none of the records marked as Resolved upon submission.
- Click File.
SQL Tables
- SYSTEM.billing_rebill_ncpdp_dur
(To view the 'DUR Override' information) - SYSTEM.billing_rebill_tx_assign
(The fields 'sub_clarification_code', 'sub_clarification_value', 'transaction_type_code' and 'transaction_type_value' are added to this table)
NCPDP Response Worklist Section
Overview
This section allows the user to view unresolved responses and flag them for resolution and mark some to be sent to RxConnect for the pharmacist to enter in the appropriate DUR and Submission Clarification Code.
Steps
- In the From Date (of Service) field, enter the start date for your search.
- In the Through Date (of Service) field, enter the end date for your search.
- In the Guarantor field, select NCPDP guarantor.
- In the Individual or All Clients field:
- Select Individual to search for response information for a specific client.
- In the Client field, select the specific client.
- Select All Clients to search for all response information.
- In the Include the Following field, select the desired criteria to refine the search:
- All Resolved Items - Selecting this will show all resolved items in the worklist.
- All Unresolved Items - Selecting this will show all unresolved items in the worklist.
- All Unresolved Items Flagged for Pharmacy (no response) - Selecting this will show all unresolved items that are flagged for pharmacy response which has not yet been addressed by the pharmacy staff.
- All Unresolved items Flagged for Pharmacy (with response) - Selecting this will show all unresolved items that are flagged for pharmacy response in which pharmacy staff has provided a response.
- Click View Worklist to launch a window displaying all of the B1 and B2 response data based on the criteria entered above.
For NCPDP billing, the Forward to Pharmacy field must be populated to flag the responses to be sent to RxConnect.
NCPDP Responses within RxConnect
When rebilling records are flagged for Pharmacy they are sent to RxConnect to be addressed by the pharmacist. This is done within the NCPDP Responses section under RxSummary.
Double-clicking the record will allow the pharmacist to enter the DURs and/or Submission Clarification Codes. After submitting, these will go back to myAvatar to be available for rebilling.
You also have easy access to the Prior Authorization section and Billing Notes.
The billing notes will indicate the rebilling history.