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NCPDP System Defaults - PM

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Define the system settings for NCPDP functionality at the Root System Code level.

Prerequisites:

Avatar PM > System Maintenance > System Definition > NCPDP System Defaults

  1. In the Output Path On Server for NCPDP Files field, enter the location on the server where myAvatar will place claims data that will be picked up by the CE2000 software for the creation of NCPDP claims processing. This is the inbound path for CE2000.
     The path + the file name and extension cannot exceed 50 characters (CE2000 limitation).
  2. In the Input Path On Server for NCPDP Response Files field, enter the location where the CE2000 software will place all response files to be imported by Avatar. This is the outbound path for CE2000.
  3. In the Plan ID field, enter the Plan ID number used to identify the proper plan to use in the CE2000 software when converting the myAvatar claims data into the NCPDP billing format. If that Plan ID is entered into the Guarantors/Payors form, then it overrides the default.
  4. In the Pharmacy NPI Number field, enter the National Provider Identifier to use when converting the claim information into the NCPDP billing format. This corresponds to the Service Provider ID (201-B1) segment within the CE2000 software.
  5. In the CMS Part D Qualified Facility field, select whether or not the facility qualifies for the CMS Part D benefit. This corresponds to the CMS Part D Defined Qualified Facility (997-G2) segment within the CE2000 software.
  6. In the Prescription Origin Code field, select the value to populate within the Prescription Origin Code (419-DJ) segment of the NCPDP file.
  7. In the Payors That Support Rebilling (B3) field, select the guarantors/payors that are able to choose the claim rebill (B3) transaction type that is available as part of the electronic re-billing process. This field is populated with all guarantors that are classified as NCPDP guarantors, as determined by the System Financial Class extended element off of the Financial Class dictionary. This works with the Claim Rebilling (B3) to the Transaction Type dictionary on the NCPDP Re-billing Service Assignment section of the Electronic Re-billing Service Assignment form. 
  8. In the Days Supply Rounding Logic field, select how the Days Supply value from the National Drug Code Reporting form will be rounded for inclusion in the NCPDP claim. The value in the form itself always remains unchanged.
    • Always round down to the whole unit
    • Always round up to the whole unit (This is the default behavior.)
    • Round up to whole unit if fractional value is .5 or greater, else round down
  9. In the Don't Bill A Claim If The Claim Amount Is Less Than The Following field, enter the minimum amount (Gross Amount Due: 430-DU) necessary for a claim to be picked up for billing. Because the default behavior is to pick up all claims regardless of claim amount, this field allows you to not bill any service/claim if the dollar amount is less than the amount specified. Any claim excluded for this reason will be shown on the billing error report.
  10. In the Pharmacy Billing Mode field, select whether the pharmacy system generates charges on administration or dispense during the Roll-Up Worklist compile.

    • If this field is valued as Bill on administration, then the roll-up date of service will always be the same as the date of the first component service. An indicator will be shown on the report if there is any overlap with a prior service/fill.
      In addition, the system assumes that the days supply amount of a roll-up service will not exceed the default days supply amount specified (though this is not enforced).

    • If this field is valued as Bill on dispense, then the roll-up date of service will either be the same as the date of the first component service or the date of the prior fill, if any, plus the days supply of the prior fill, whichever is later. This is done to eliminate any service overlap.
      In addition, the system will prevent the days supply amount of a roll-up service/fill from ever exceeding the default days supply amount specified.

    • If this field is not valued then the system assumes Bill on administration.

Roll-Up Worklist Specific

  1. In the Default Fill Days Supply field, enter the default number of fill days for NCPDP orders. This should match the frequency of the pharmacy billing cycle at the facility. If pharmacy charges are billed every 28 days, then set this value to "28". The maximum amount allowed is 30 days.
     This value defaults to "28" automatically if no other value is defined. This value is used by the roll-up process when a 'fill' days supply is not defined on the order level.
    • The Default Fill Days Supply value will default into the Expected Days Supply field on the Client Profile/Physicians Orders form in myAvatar OE if no other value is present.
    • This value is also used as the Fill Days Supply value for all services. Previously, the system would look first to the order associated with the service and, if no value was found, use the value defined at the facility level. The Fill Days Supply value is used by the system to limit the number of services that can be rolled up into a single item.  
  2. In the Surcharge Amount field, enter the value of the additional amount (dispensing fee) that will be added to each rolled-up item created via the Roll-Up Worklist for the NCPDP rule definition, if applicable.
     
  3. Click Submit.