Attachment J -DEI Billing Procedure Document.pdf

Attachment J

Pharmacy Benefit Manager (PBM)

1. Invoicing.

The Financial Management Branch (FMB) within the Department of Employee Insurance (DEI) shall be billed for all contractually applicable Kentucky Employees’ Health Plan (KEHP) costs, both during and after the Implementation, on a weekly or monthly basis.

The FMB shall receive weekly claims files for payment, and weekly claim processing fee invoices from the Vendor. The FMB shall receive monthly administration invoices and supporting files from the Vendor for services and programs.

Monthly invoices must be submitted by the Vendor to FMB between the first (1st) and fifteenth (15th) day of each month for the Services performed and expenses incurred during the prior calendar month. As an example and for clarity, January invoices must be received by FMB between February 1st and 15th.

Weekly invoices must be submitted by the Vendor to FMB by the 2nd day of each week, at the latest, for Services performed and expenses incurred during the prior calendar week, which is defined as the seven (7) day period of Sunday through Saturday. As an example and for clarity, services performed and expenses incurred January 14 thru January 20, 2024, would be submitted to FMB on the January 23, 2024, invoice.

FMB will not remit payment to the Vendor until services have occurred, and interest penalties shall be assessed in accordance with KRS 45.454.

2. Invoice Format.

The Vendor shall bill all eligible KEHP expenses to FMB on the Vendor’s invoice in PDF format.

The invoice must contain the following:

• Invoice Number

• Invoice Date

• Month/Period of Service being Billed

• Payment Due Date

• Description of Charge(s), with billable items grouped by covered service as specified in the contract

• Total Amount Due for each item/row on the bill

• Total Amount due for Invoice

3. Supporting Files and Reports Format

All contractually applicable KEHP goods & services invoiced to FMB must be supported by corresponding records on the supporting report(s) or file(s). Supporting reports or files must arrive in Excel or CSV format.

Weekly Claims:

The record for a pharmacy claim dispensed to a KEHP member for which the FMB must remit payment shall include data listed within the attached layout, KEHP Pharmacy Claims Invoicing File.

Monthly Administrative Services:

The records which support KEHP monthly administrative invoices shall include, at minimum:

Invoice #, Information to identify recipients of service(s), date(s) services performed or provided, description of service, quantity, charge per service, and total amount due.

Any supporting document that contains “protected health information” (as such term is defined under HIPAA and 45 C.F.R. § 160.103) or bank account information shall be transmitted via encrypted email or by way of the Personnel Cabinet’s secure file transfer protocol (FTP) service.

4. Invoice Review and Verification.

The FMB will evaluate KEHP expenses for payment upon receipt of the invoice. All invoices must be accompanied by supporting files or reports in order to be evaluated for payment, and the supporting documentation must be sufficient for the FMB to verify charges are valid and eligible for payment.

Upon approval of an invoice by the FMB, the payment for such invoice will be executed in the eMARS system, and payment will be remitted to the Vendor.

The FMB will strive to pay all correct and complete invoices within 30 working days of receipt, mindful of the obligations within the contractual agreement and KRS 45.454.

5. Concerns and Disputed Amounts on Invoice.

Upon FMB receiving and processing a KEHP invoice and supporting file, any questions or concerns will be sent to the Vendor. The Vendor will have 5 business days to answer and/or resolve the concern. If no answer or resolution by the 6th business day, the issue becomes subject to the disputed items process laid out below.

In the event an item on the invoice, or an invoice in its entirety, is disputed, i.e. rejected as per KRS 45.453, the FMB shall send the Vendor an email listing the disputed invoice and/or disputed invoice items along with the reason for the dispute. If an item is disputed, the email shall also contain the adjusted invoice amount. The remaining approved expenses shall then be paid by the FMB.

If the Vendor elects to counter the disputed (rejected) items, the Vendor shall submit to the FMB a new invoice with a new invoice number, for the disputed items only, along with additional support validating the expenses. The FMB will review the new invoice and support for consideration of payment.

The Vendor shall provide the FMB with names, emails and phone numbers of contact persons in their accounting or billing departments who shall be the primary recipients of any notice regarding a disputed expense. The FMB shall provide the like in turn.

6. Payments to FMB and Invoicing Credits

• Penalty payments for missed KEHP performance guarantees (PG) shall be made in the form of ACH or check. The FMB will not accept PG payments in the form of invoice credits. The PG payment must be accompanied by an explanatory document, such as an invoice or report, with direct indication of which PG the payment is for.

• Rebate payments for KEHP shall be made in the form of ACH or check, and must be accompanied by a supporting file or report. The FMB will not accept rebate payments in the form of invoice credits.

• Contractual warrantee payments for KEHP shall be made in the form of ACH or check, and must be accompanied by a supporting explanatory document with direct indication of which contractual agreement the payment is for, as well as supporting files and/or reports. The FMB will not accept warrantee payments in the form of invoice credits.

• Invoicing Credits on KEHP invoices must be clearly explained and delineated from other items on the invoice, and accompanied by a supporting file or report.

The vendor must follow instructions provided by FMB for submitting ACH payments to FMB. If the vendor requires additional information to enable ACH payments, contact the FMB Branch Manager, Judy Baker (Judy.Baker@ky.gov).

Vendor shall use abbreviation of KY-KEHP for the Kentucky Employee’s Health Plan as the Individual Name field of the ACH payment. Use of KY-KEHP enables the Kentucky State Treasurer, referred to as KY Treasury, to identify KEHP incoming payments.

Vendor shall list reason for payment (PG # penalty payment, rebate info, etc) and “for DEI/FMB” in addenda on payment. Please note KY Treasury accepts up to 80 characters, including spaces, for Addenda.

Vendor is required to submit an email to persfmb@ky.gov containing transmission details for all ACH payments.

In the event of an ACH payment error, Vendor shall not attempt to recall payments. Vendor shall email persfmb@ky.gov and work with the FMB group and KY Treasury for resolution.

NOTE: Kentucky State Treasurer EFT Payment Instructions will be provided separately via encrypted email.

mailto:Judy.Baker@ky.gov mailto:persfmb@ky.gov mailto:persfmb@ky.gov

Pharmacy Benefit Manager (PBM)