NCPDP Responses
In RxConnect, select billing rejections that need to be adjudicated by the pharmacy.
Prerequisites:
- This information comes from B1 Claim Responses sent from myAvatar PM and includes the DUR Reason codes and Reject codes that explain why the claim was rejected. The NCPDP responses are queried live from myAvatar PM via a web service. The myAvatar user must flag the responses to be sent to RxConnect within the myAvatar PM NCPDP Response Worklist section of the Electronic Re-Billing Service Assignment form in order to have DUR and Submission Clarification Codes assigned, either in myAvatar or by the pharmacist in RxConnect.
- The NCPDP Responses summary lists the rejections by order number, Rx number, status, patient name, account number, nursing unit, payor, staff person's name, and drug name. In the Status column, the 'R' is the value the payor returned to myAvatar as a result of processing the claim and indicates the claim was rejected and flagged for sending to the pharmacy. The Pcy Hold (Pharmacy Hold) column indicates there is a saved response for the item that is on hold and has yet to be submitted. The summary list shows only the latest response for a client, order, NDC, and Transaction/Dispense/Service Date combination.
- The Start and End fields default to a 60-day range ending at the current hospital time. If one of the fields is blank, refreshing the page defaults the blank item to 60 days from the non-blank item. If both fields are blank, the default range is used.
- Click on an item in the summary list to display the NCPDP Response detail screen where the pharmacist can enter information used to resubmit rejected claims or choose to not resubmit claims. Once the pharmacist submits a response on the NCPDP Responses detail screen, the NCPDP Responses summary displays a result message for the submitted item and removes it from the summary list.
NCPDP Responses Detail Screen
RxConnect > RxSummary > NCPDP Responses
Use the NCPDP Responses detail screen to review details about a billing rejection and adjudicate rejected claims. Click on an item in the NCPDP Responses section of the RxSummary Screen to display the NCPDP Responses detail screen. From this screen the pharmacist reviews the B1 Transaction Response sent from myAvatar PM and choose to resubmit the claim, not resubmit the claim, or place the claim response on hold.
The B1 Transaction Response from myAvatar PM includes the following information:
- Patient and claim identification
- Up to 20 reject codes
- Up to 2 Additional Messages
- Up to 3 sets of DUR (Drug Utilization Review) alerts, with the following information in each set:
- DUR Reason for Service Code
- Clinical Significance Code
- DUR Free Text Message
- DUR Additional Text
If the rejection code represents a DUR rejection, it will be accompanied by the DUR Reason code. DUR rejection codes provide the clinical reason for the rejection.
In response to the claim rejection, the pharmacist enters DUR Reason codes and Submission Clarification codes. The DUR Reason codes (Reason for Service code, Professional Service code, and Results of Service code) and Submission Clarification codes are necessary to provide clinical reasons why a specific claim was dispensed a certain way. myAvatar PM includes this information in the claims resubmitted to the Switch/PDP.
Each grouping in the Response DUR Reason Codes section consists of six codes:
- Reason for Service - Indicates the reason the pharmacist provided the service. Some examples: the pharmacist determined an additional drug was needed; circumstances required the pharmacist to verify the validity of the prescription, etc.
- Professional Service - The service rendered by the pharmacist (patient assessment, dosage evaluated, prescriber consulted, etc.).
- Result of Service - A cognitive service performed by the pharmacist, such as the review and evaluation of a therapeutic issue, and the resulting action, such as filing a prescription with a different dose or changing from a banded product to a generic project.
- DUR/PPS Level of Effort - Indicates the level of effort for performing the service. This information is usually included when submitting compound segments.
- DUR Co-Agent ID Qualifiier - Identifies the category used to qualify the service, such as Universal Product Code (UPC). This qualifier is needed when submitting a Reason for Service Code for some payers.
- DUR Co-Agent ID - Identifies the co-existing agent contributing to the DUR event, such as prompting a pharmacist professional service. This is ID needed when submitting a Reason for Service Code for some payers.
Submission Clarification codes provide additional information explaining why a particular action was taken for the medication order. For example, the pharmacist would use a Submission Clarification code to indicate the physician determined that a change in medication was required because a different dosage form was needed. The pharmacist can specify up to three Submission Clarification codes.
The selections available for the DUR Reason codes (Reason for Service code, Professional Service code, and Results of Service code) and Submission Clarification codes in RxConnect are maintained in myAvatar PM.
NCPDP processing supports up to nine sets of DUR data and up to three Submission Clarification codes when submitting rebills. For this reason the pharmacist can enter up to nine groups of DUR information and up to three Submission Clarification codes in RxConnect.
To adjudicate billing rejections:
- In the NCPDP Response summary list, click on an item to display the NCPDP Responses detail screen.
- Review details about the rejected claim including the Reject codes, Additional DUR Free text message and Additional text.
- In the Response DUR Reason Codes sections, enter appropriate responses for up to nine occurrences of each group of six items.
- Select up to three Submission Clarification codes.
- If responses data will not be sent to myAvatar PM, select one of the following options:
- No Rebill - Send a message to myAvatar PM not to rebill the claim. No data entered on the form is sent to myAvatar PM.
- No Action - Indicate to myAvatar PM that no action should be taken on the claim. No data entered on the form is sent to myAvatar PM.
- If response data will be sent to myAvatar PM, select one of the following options:
- Pcy Hold - Save the response data for submission at a later time. On the summary list, the Pcy Hold column will indicate the data was saved.
- Submit - Submit the response data to myAvatar PM to use for rebilling.
- Click Return to go back to the NCPDP Responses summary list.