Section_19_Pharmacy_Legacy_version_20140106.doc

Requirements Specification Document (LEGACY DRAFT)

Pharmacy (Section 19)

Central Bill Process

Pharmacy (PWS Section 19)

Requirements Specification Document

(LEGACY DRAFT)

Prepared for:

U.S. Department of Labor

Office of Worker’s Compensation Programs

Revision History:

SPECIAL NOTICE: This document is a legacy draft requirements specification document developed between 2011 and 2012. As outlined in the Performance Work Statement, the Contractor will be required to review this RSD and make appropriate updates wherever necessary. (Please refer to PWS R0052 for more details.)

Table of Contents Pharmacy - DFEC

61.1 Pharmacy Overview - DFEC

71.2 Pharmacy Business Process Description - DFEC

71.2.1 Access to Pharmacy Bill Data

71.2.2 Custom Messaging Features

71.2.3 Explanation of Benefits (EOBs)

71.2.4 Compound Bills Processing

71.2.5 Data Validation and Edits

81.2.5.1 Edits for Obsolete Drugs

81.2.5.2 Exception Reviews and Authorizations

81.2.6 Drug Pricing

81.2.6.1 Pharmaceutical Rebate Program

81.2.7 Processing Pharmacy Charges Submitted on OWCP 1500 Form

91.2.8 Bills Retention

101.3 Pharmacy Business Process Flow – DFEC

Pharmacy - DEEOIC

112.1 Pharmacy Overview – DEEOIC

122.2 Pharmacy Business Process Description - DEEOIC

122.2.1

122.2.2

122.2.3

122.2.4

122.2.5

132.2.5.1

132.2.5.2

132.2.6

132.2.6.1

132.2.7

142.2.8

152.3 Pharmacy Business Process Flow – DEEOIC

Pharmacy – DCMWC

163.1 Pharmacy Overview – DCMWC

173.2 Pharmacy Business Process Description - DCMWC

173.2.1

173.2.2

173.2.3

173.2.4

173.2.5

183.2.5.1

183.2.5.2

183.2.6

183.2.6.1

183.2.7

193.2.8

203.3 Pharmacy Business Process Flow – DCMWC

Pharmacy Business Requirements

214.1 Functional Requirements

234.2 Business Rules

Pharmacy Supporting Functional Components

335.1 Initial Data Migration

335.2 Interfaces

345.3 Reports

385.4 Letters

Constraints

396.1 Assumptions

396.2 Dependencies

396.3 Issues/Open Items

Appendices

407.1 Terms & Definitions

457.2 Pharmacy Edits - DFEC

577.3 Pharmacy Edits - DEEOIC

687.4 Pharmacy Edits - DCMWC

1 Pharmacy - DFEC

1.1 Pharmacy Overview - DFEC

The Contractor will implement a pharmacy solution that is fully compliant with NCPDP standards and that handles all types of pharmacy bills — paper, EDI and point-of-sale (POS). A key component of the pharmacy solution will be the integration of treatment suites to ensure the appropriate National Drug Codes (NDC) therapeutic class (TXCL) or Generic Code Nomenclature (GCN) is covered based on the claimant’s accepted condition. When program requirements change and processing rules must be added, modified, or deleted, the pharmacy bill process will be modified to meet the processing modifications required.

The Contractor will integrate an automated workflow process for the flow of requests and bill processing results. The Contractor will process all pharmacy bills using the same processing engine (bill processing/adjudication system) regardless of bill origin, electronic (batch or POS) and paper bills (pharmacy or claimant-submitted), using NCPDP-compliant transactions; however, pharmacy bills will then enter the pharmacy adjudication system. Paper pharmacy bills will be processed according to the same rules for the processing of paper medical bill processing rules; pharmacy bill data will be data entered into pharmacy bill process instead of the medical bill process. Retail pharmacy bills will be submitted from pharmacies to the Pharmacy Benefit Manager (PBM) center via commercial switches (VANs), or directly from independent pharmacies via dial-up. Pharmacy bills can also be received in batch mode and submitted using any industry-standard electronic media.

The Contractor’s pharmacy solution will also provide the following services:

· Batch and Web services interfaces for bills history/bills extract for the Contractor CBP, EOB development, RVs, and reporting

· Extensive custom messaging features to enhance the information available to pharmacies and to aid in services to DOL claimants

· EOBs for every direct recipient reimbursement bill

· Ability to process multi-ingredient compounds using multiple methodologies, which can be used to contain costs and process according to DOL rules

· System processing edits for included/excluded drugs, obsolete drugs, medical supplies, and/or devices, as defined by DOL treatment suites and/or DOL policy

· Pricing that supports AWP, pharmaceutical rebate programs (if implemented), clinical intervention programs, step therapy, and other drug management support

· Capability to identify duplicate prescriptions prior to dispensing the second prescription, including the added ability to control where a potential abuse situation may be of concern

· Full service pharmacy call center support for pharmacies, prescribers, and claimants from 8:00 a.m. until 11:00 p.m. ET, Monday through Friday

· Pharmacy POS will be available 24x7 (except during scheduled maintenance timeframes which will be pre-authorized by DOL and clearly communicated to pharmacists in advance)

1.2 Pharmacy Business Process Description - DFEC

1.2.1 Access to Pharmacy Bill Data

Approved users will have electronic access to pharmacy bill data, including query capability, through the CBP Web Portal. Pharmacy bill data will also be available in pharmacy bill process; however, as pharmacy bills are processed they are sent to the medical bill process to be consolidated into the master bill file. The CBP portal accesses the medical bill process consolidated bill file to provide a comprehensive view of all bill data.

1.2.2 Custom Messaging Features

The pharmacy bill process will have extensive custom messaging features to enhance the information available to pharmacies and to aid in services to DOL claimants. Online messages will be sent back to the submitting pharmacy with the bill response, which will include rejected bills (including denials for duplicate bills and third-party denials, specific bills for an individual group and/or population, etc.). The pharmacy bill process will utilize rejection messaging consistent with NCPDP standards related to specific rejection codes. Messages will be based on specific DOL program requirements and will be prioritized based on the functional area within the bill processing system that originated the message, including treatment suites and patient authorizations. If more than one message occurs of equal priority, messages will be processed in a first-in, first-out order. Custom messages and new messages can be created at any time and will be immediately available to submitting pharmacies.

1.2.3 Explanation of Benefits (EOBs)

Using the pharmacy bill process, EOBs will be produced for every direct recipient reimbursement bill and several templates will be offered for DOL to review/approve, customize if needed, and to implement. There is a one-to-one mapping for all edits between the pharmacy bill process and the medical bill process. Pharmacy processing will produce EOB codes directly related to NCPDP and the pharmacy bill process error clarification codes.

1.2.4 Compound Bills Processing

The pharmacy bill process will offer the option of single ingredient or multi-ingredient compound bills processing. The pharmacy bill process single ingredient option will support the current DOL compounded drug prescription coding policy. The pharmacy bill process will either process the compound using a single submitted NDC, representing the most expensive or active ingredient, or as a multi-ingredient compound using all of the NDCs submitted, as defined in the NCPDP 5.1 standard. In either case, the Contractor will have the option of denying the bill if the single NDC, or any of the multiple NDCs, are not considered compoundable according to MediSpan drug data.

1.2.5 Data Validation and Edits

The pharmacy bill processing solution will incorporate system processing edits for included/excluded drugs, medical supplies, and/or devices, as defined by DOL Treatment Suites and/or DOL policy. All bills will be validated for compliance with NCPDP Release 5.1 standards and will be edited to the fullest extent possible, so as to provide maximum information for resubmission of the bill.

Pharmacy updates will not occur until closer to go-live or post go-live because ACS is maintaining the Production databases for these applications, and the Contractor cannot afford to be out of sync with them. The Contractor will work with DOL during the Transition period on these changes, and coordinate them with ACS.

1.2.5.1 Edits for Obsolete Drugs

The drug database will provide the date that a drug receives the status of “obsolete”. This may be for a variety of reasons, including: pharmaceutical manufacturer statement or pharmaceutical manufacturer non-responsiveness. The Contractor will have the ability to set a flag to reject the Rx claim for an “obsolete” drug based on “x” days past the obsolete date provided on the drug database file. The number of days is generally provided by the client. According to DOL per ACS PBM, "the OWCP will allow the payment of drugs that are obsolete, 2 years past the Manufacturer’s obsolete date as referenced in the file." The Contractor will support the payment of drugs that are obsolete 2 years past the manufacturer’s obsolete date. Three years after the obsolete date, drugs deemed obsolete will not receive updates such as drug interactions, pricing or other attributes that may be pertinent to the chemical entity and product. The information associated with the NDC becomes static at that time, though the NDC remains in the drug database.

1.2.5.2 Exception Reviews and Authorizations

The pharmacy bill process will require exception reviews/authorizations based upon type of drug (class), specific drug name/NDC, pricing (e.g., giving DCMWC the ability to review any bills greater than $750 and/or all narcotics as requested), and other bill attributes. The pharmacy bill process also will provide “lock-in” capability, wherein DOL policy will be supported to ensure specific claimants can only get specific drugs from specific prescribers and pharmacies. Additionally, the pharmacy bill process will support exception processing in the form of overrides consistent with DOL policy.

1.2.6 Drug Pricing

The Contractor will support the use of MediSpan files as the primary source of drug data and pricing. Pricing for drugs will be implemented according to the three different OWCP programs’ needs. Flat dispensing fees, discounts, co-pays, and/or third-party liabilities will be calculated based on the individual DOL programs. The Contractor will utilize AWP as provided MediSpan data files. The pricing will be based on AWP-5% plus $4.00 dispensing fee for all drugs and all programs.

1.2.6.1 Pharmaceutical Rebate Program

The purpose and benefit of the pharmaceutical manufacturer rebates includes revenue support to the program. Preferred status of the pharmaceutical product (e.g., Covered versus non-Covered) can generate retrospective discounts toward the program’s cost of the drugs.

1.2.7 Processing Pharmacy Charges Submitted on OWCP 1500 Form The Contractor will implement a process in which the NDC and quantity submitted on a physician submitted drug bill (OWCP 1500) will be captured at data entry along with the accompanying ‘J’ code. The physician submitted bill will process through Treatment Suites following the 1500 path, checking billed diagnosis codes against the claimant's accepted condition, and ensuring the billed procedure (in this case the 'J' code) is covered. The 'J' code will be a covered service in Treatment Suites, but will have a Control Code set to Review/Suspend, causing the bill to suspend.

As part of the bill resolution process, the NDC and quantity submitted will be used to manually obtain an AWP price in the Pharmacy system. Once obtained, the Pharmacy price will be manually applied to the professional bill. This ensures pricing is based upon the NDC and specific quantities billed, rather than the J code which is currently set to 'pay as billed'. An Eligibility inquiry will also be performed to ensure the Therapeutic class for the billed NDC is covered for the claimant's accepted condition. If the call to Treatment Suites fails, the bill will deny for the appropriate treatment suite edit.

Paper bills submitted by pharmacies will be received in the CBP Central Mailroom and be subjected to the standard Front-End processes. They will be routed via workflow to a queue to be keyed into the pharmacy bill process, and will process and adjudicate just as a POS Pharmacy bill will, subjected to all the Pharmacy edits and pricing logic.

1.2.8 Bills Retention

The Contractor will retain all DOL pharmacy bill data for use in editing EOBs and RVs. All edits or exceptions will be available within the medical bill process for every bill processed. The Contractor will provide access to pharmacy bill data using the medical bill process for specific bill data, including denials (rejections) with reason codes. The Contractor will also provide standard and ad hoc reports via CBP Web Portal.

1.3 Pharmacy Business Process Flow – DFEC

The following diagram captures the DFEC Pharmacy Business Process flow.

SHAPE \* MERGEFORMAT

2 Pharmacy - DEEOIC

2.1 Pharmacy Overview – DEEOIC

The Contractor will implement a pharmacy solution that is fully compliant with NCPDP standards and that handles all types of pharmacy bills — paper, EDI and point-of-sale (POS). ’s Pharmacy bill process service will be designed and developed explicitly for pharmacy bill processing. A key component of the pharmacy solution is the integration of treatment suites to ensure the appropriate National Drug Codes (NDC) therapeutic class (TXCL) or Generic Code Nomenclature (GCN) is covered based on the claimant’s accepted condition. When program requirements change and processing rules must be added, modified, or deleted, the pharmacy bill process will be modified through table-driven rules to meet the processing modifications required.

The Contractor will integrate an automated workflow process for the flow of requests and bill processing results. The Contractor will process all pharmacy bills using the same processing engine (bill processing/adjudication system) regardless of bill origin, electronic (batch or POS) and paper bills (pharmacy or claimant-submitted), using NCPDP-compliant transactions; however, pharmacy bills will then enter the pharmacy adjudication system. Paper pharmacy bills will be processed according to the same rules for the processing of paper medical bill processing rules; pharmacy bill data will be entered into the pharmacy bill process instead of the medical bill process. Retail pharmacy bills will be submitted from pharmacies to the Pharmacy Benefit Manager (PBM) center via commercial switches (VANs), or directly from independent pharmacies via dial-up. Pharmacy bills can also be received in batch mode and submitted using any industry-standard electronic media.

The Contractor’s pharmacy solution will also provide the following services:

· Batch and Web services interfaces for bills history/bills extract for the the Contractor’s CBP medical bill process, EOB development, RVs, and reporting

· Extensive custom messaging features to enhance the information available to pharmacies and to aid in services to DOL claimants

· EOBs for every direct recipient reimbursement bill

· Ability to process multi-ingredient compounds using multiple methodologies, which can be used to contain costs and process according to DOL rules

· System processing edits for included/excluded drugs, obsolete drugs, medical supplies, and/or devices, as defined by DOL treatment suites and/or DOL policy

· Pricing that supports AWP, pharmaceutical rebate programs (if implemented), clinical intervention programs, step therapy, and other drug management support

· Capability to identify duplicate prescriptions prior to dispensing the second prescription, including the added ability to control where a potential abuse situation may be of concern

· Full service pharmacy call center support for pharmacies, prescribers, and claimants from 8:00 a.m. until 11:00 p.m. ET, Monday through Friday

· Pharmacy POS will be available 24x7 (except during scheduled maintenance timeframes which will be pre-authorized by DOL and clearly communicated to pharmacists in advance)

2.2 Pharmacy Business Process Description - DEEOIC

2.2.1 Access to Pharmacy Bill Data

Approved users will have electronic access to pharmacy bill data, including query capability, through the CBP Web Portal. Pharmacy bill data will also be available in the pharmacy bill process; however, as pharmacy bills are processed through the pharmacy bill process, they are sent to the medical bill process to be consolidated into the master bill file. The CBP portal accesses the medical bill process consolidated bill file to provide a comprehensive view of all bill data.

2.2.2 Custom Messaging Features

The pharmacy bill process will have extensive custom messaging features to enhance the information available to pharmacies and to aid in services to DOL claimants. Online messages will be sent back to the submitting pharmacy with the bill response, which will include rejected bills (including denials for duplicate bills and third-party denials, specific bills for an individual group and/or population, etc.). The Contractor will utilize rejection messaging consistent with NCPDP standards related to specific rejection codes. Messages will be based on specific DOL program requirements and will be prioritized based on the functional area within the bill processing system that originated the message, including treatment suites and patient authorizations. If more than one message occurs of equal priority, messages will be processed in a first-in, first-out order. Custom messages and new messages can be created at any time and will be immediately available to submitting pharmacies.

2.2.3 Explanation of Benefits (EOBs)

Using the pharmacy bill process, EOBs will be produced for every direct recipient reimbursement bill and several templates will be offered for DOL to review/approve, customize if needed, and to implement. There is a one-to-one mapping for all edits between the pharmacy bill process and the medical bill process. Pharmacy processing will produce EOB codes directly related to NCPDP and the pharmacy bill process error clarification codes.

2.2.4 Compound Bills Processing

The pharmacy bill process will offer the option of single ingredient or multi-ingredient compound bills processing. The pharmacy bill process single ingredient option will support the current DOL compounded drug prescription coding policy. The pharmacy bill process will either process the compound using a single submitted NDC, representing the most expensive or active ingredient, or as a multi-ingredient compound using all of the NDCs submitted, as defined in the NCPDP 5.1 standard. In either case, the Contractor will have the option of denying the bill if the single NDC, or any of the multiple NDCs, are not considered compoundable according to MediSpan drug data.

2.2.5 Data Validation and Edits

The pharmacy bill processing solution will incorporate system processing edits for included/excluded drugs, medical supplies, and/or devices, as defined by DOL Treatment Suites and/or DOL policy. All bills will be validated for compliance with NCPDP Release 5.1 standards and will be edited to the fullest extent possible, so as to provide maximum information for resubmission of the bill.

Pharmacy updates will not occur until closer to go-live or post go-live because the previous vendor is maintaining the Production databases for these applications, and the Contractor cannot afford to be out of sync with them. The Contractor will work with DOL during the Transition period on these changes, and coordinate them with the previous vendor.

2.2.5.1 Edits for Obsolete Drugs

The drug database provides the date that a drug receives the status of “obsolete”. This may be for a variety of reasons, including: pharmaceutical manufacturer statement or pharmaceutical manufacturer non-responsiveness. The Contractor will have the ability to set a flag to reject the Rx claim for an “obsolete” drug based on “x” days past the obsolete date provided on the drug database file. The number of days is generally provided by the client. The Contractor will support the payment of drugs that are obsolete 2 years past the manufacturer’s obsolete date. Three years after the obsolete date, drugs deemed obsolete will not receive updates such as drug interactions, pricing or other attributes that may be pertinent to the chemical entity and product. The information associated with the NDC becomes static at that time, though the NDC remains in the drug database.

2.2.5.2 Exception Reviews and Authorizations

The pharmacy bill process will require exception reviews/authorizations based upon type of drug (class), specific drug name/NDC, pricing (e.g., giving DCMWC the ability to review any bills greater than $750 and/or all narcotics as requested), and other bill attributes. The pharmacy bill process also will provide “lock-in” capability, wherein DOL policy will be supported to ensure specific claimants can only get specific drugs from specific prescribers and pharmacies. Additionally, the pharmacy bill process will support exception processing in the form of overrides consistent with DOL policy.

2.2.6 Drug Pricing

The Contractor will support the use of the MediSpan files as the primary source of drug data and pricing. Pricing for drugs will be implemented according to the three different OWCP programs’ needs. Flat dispensing fees, discounts, co-pays, and/or third-party liabilities will be calculated based on the individual DOL programs. The Contractor will utilize AWP as provided by MediSpan data files. The pricing will be based on AWP-5% plus $4.00 dispensing fee for all drugs and all programs.

2.2.6.1 Pharmaceutical Rebate Program

The purpose and benefit of the pharmaceutical manufacturer rebates includes revenue support to the program. Preferred status of the pharmaceutical product (e.g., Covered versus non-Covered) can generate retrospective discounts toward the program’s cost of the drugs.

2.2.7 Processing Pharmacy Charges Submitted on OWCP 1500 Form

The Contractor will implement a process in which the NDC and quantity submitted on a physician submitted drug bill (OWCP 1500) will be captured at data entry along with the accompanying ‘J’ code. The physician submitted bill will process through Treatment Suites following the 1500 path, checking billed diagnosis codes against the claimant's accepted condition, and ensuring the billed procedure (in this case the 'J' code) is covered. The 'J' code will be a covered service in Treatment Suites, but will have a Control Code to set to Review/Suspend, causing the bill to suspend.

As part of the bill resolution process, the NDC and quantity submitted will be used to manually obtain an AWP price in the Pharmacy system. Once obtained, the Pharmacy price will be manually applied to the professional bill. This ensures pricing is based upon the NDC and specific quantities billed, rather than the J code which is currently set to 'pay as billed'. An Eligibility inquiry will also be performed to ensure the Therapeutic class for the billed NDC is covered for the claimant's accepted condition. If the call to Treatment Suites fails, the bill will deny for the appropriate treatment suite edit.

Paper bills submitted by pharmacies will be received in the CBP Central Mailroom and be subjected to the standard Front-End processes. They will be routed via workflow to a queue to be keyed into the pharmacy bill process, and will process and adjudicate just as a POS Pharmacy bill will, subjected to all the Pharmacy edits and pricing logic.

2.2.8 Bills Retention

The Contractor will retain all DOL pharmacy bill data for use in editing EOBs and RVs. All edits or exceptions will be available within the medical bill process for every bill processed. The Contractor will provide access to pharmacy bill data using the medical bill process for specific bill data, including denials (rejections) with reason codes. The Contractor will also provide standard and ad hoc reports via CBP Web Portal.

2.3 Pharmacy Business Process Flow – DEEOIC

The following diagram captures the DEEOIC Pharmacy Business Process flow.

3 Pharmacy – DCMWC

3.1 Pharmacy Overview – DCMWC

The Contractor will implement a pharmacy solution that is fully compliant with NCPDP standards and that handles all types of pharmacy bills — paper, EDI and point-of-sale (POS). . ’s A key component of the pharmacy solution will be the integration of treatment suites to ensure the appropriate National Drug Codes (NDC) therapeutic class (TXCL) or Generic Code Nomenclature (GCN) is covered. When program requirements change and processing rules must be added, modified, or deleted, the pharmacy bill process will be modified through table-driven rules to meet the processing modifications required.

The Contractor will integrate an automated workflow process for the flow of requests and bill processing results. The Contractor will process all pharmacy bills using the same processing engine (bill processing/adjudication system) regardless of bill origin, electronic (batch or POS) and paper bills (pharmacy or claimant-submitted), using NCPDP-compliant transactions; however, pharmacy bills will then enter the pharmacy adjudication system. Paper pharmacy bills will be processed according to the same rules for the processing of paper medical bill processing rules; pharmacy bill data will be data entered into the pharmacy bill process instead of the medical bill process. Retail pharmacy bills will be submitted from pharmacies to the Pharmacy Benefit Manager (PBM) center via commercial switches (VANs), or directly from independent pharmacies via dial-up. Pharmacy bills can also be received in batch mode and submitted using any industry-standard electronic media.

The Contractor’s pharmacy solution will also provide the following services:

· Batch and Web services interfaces for bills history/bills extract for the Contractor’s CBP medical bill process, EOB development, RVs, and reporting

· Extensive custom messaging features to enhance the information available to pharmacies and to aid in services to DOL claimants

· EOBs for every direct recipient reimbursement bill

· Ability to process multi-ingredient compounds using multiple methodologies, which can be used to contain costs and process according to DOL rules

· System processing edits for included/excluded drugs, obsolete drugs, medical supplies, and/or devices, as defined by DOL treatment suites and/or DOL policy

· Pricing that supports AWP, pharmaceutical rebate programs (if implemented), clinical intervention programs, step therapy, and other drug management support

· Capability to identify duplicate prescriptions prior to dispensing the second prescription, including the added ability to control where a potential abuse situation may be of concern

· Full service pharmacy call center support for pharmacies, prescribers, and claimants from 8:00 a.m. until 11:00 p.m. ET, Monday through Friday

· Pharmacy POS will be available 24x7 (except during scheduled maintenance timeframes which will be pre-authorized by DOL and clearly communicated to pharmacists in advance)

3.2 Pharmacy Business Process Description - DCMWC

3.2.1 Access to Pharmacy Bill Data

Approved users will have electronic access to pharmacy bill data, including query capability, through the CBP Web Portal. Pharmacy bill data will also be available in the pharmacy bill process; however, as pharmacy bills are processed through the pharmacy bill process, they will be sent to the medical bill process to be consolidated into the master bill file. The CBP portal accesses the medical bill process consolidated bill file to provide a comprehensive view of all bill data.

3.2.2 Custom Messaging Features

The pharmacy bill process will have extensive custom messaging features to enhance the information available to pharmacies and to aid in services to DOL claimants. Online messages will be sent back to the submitting pharmacy with the bill response, which will include rejected bills (including denials for duplicate bills and third-party denials, specific bills for an individual group and/or population, etc.). The Contractor will utilize rejection messaging consistent with NCPDP standards related to specific rejection codes. Messages will be based on specific DOL program requirements and will be prioritized based on the functional area within the bill processing system that originated the message, including treatment suites and patient authorizations. If more than one message occurs of equal priority, messages will be processed in a first-in, first-out order. Custom messages and new messages can be created at any time and will be immediately available to submitting pharmacies.

3.2.3 Explanation of Benefits (EOBs)

Using the pharmacy bill process, EOBs will be produced for every direct recipient reimbursement bill and several templates will be offered for DOL to review/approve, customize if needed, and to implement. There is a one-to-one mapping for all edits between the pharmacy bill process and the medical bill process. Pharmacy processing will produce EOB codes directly related to NCPDP and the pharmacy bill process error clarification codes.

3.2.4 Compound Bills Processing

The pharmacy bill process will offer the option of single ingredient or multi-ingredient compound bills processing. The pharmacy bill process single ingredient option will support the current DOL compounded drug prescription coding policy. The pharmacy bill system will either process the compound using a single submitted NDC, representing the most expensive or active ingredient, or as a multi-ingredient compound using all of the NDCs submitted, as defined in the NCPDP 5.1 standard. In either case, the Contractor will have the option of denying the bill if the single NDC, or any of the multiple NDCs, are not considered compoundable according to MediSpan drug data.

3.2.5 Data Validation and Edits

The pharmacy bill processing solution will incorporate system processing edits for included/excluded drugs, medical supplies, and/or devices, as defined by DOL Treatment Suites and/or DOL policy. All bills will be validated for compliance with NCPDP Release 5.1 standards and will be edited to the fullest extent possible, so as to provide maximum information for resubmission of the bill.

Pharmacy updates will not occur until closer to go-live or post go-live because the previous vendor is maintaining the Production databases for these applications, and the Contractor cannot afford to be out of sync with them. The Contractor will work with DOL during the Transition period on these changes, and coordinate them with the previous vendor.

3.2.5.1 Edits for Obsolete Drugs

The drug database will provide the date that a drug receives the status of “obsolete”. This may be for a variety of reasons, including: pharmaceutical manufacturer statement or pharmaceutical manufacturer non-responsiveness. The Contractor will have the ability to set a flag to reject the Rx claim for an “obsolete” drug based on “x” days past the obsolete date provided on the drug database file. The number of days is generally provided by the client The Contractor will support the payment of drugs that are obsolete 2 years past the manufacturer’s obsolete date. Three years after the obsolete date, drugs deemed obsolete will not receive updates such as drug interactions, pricing or other attributes that may be pertinent to the chemical entity and product. The information associated with the NDC becomes static at that time, though the NDC remains in the drug database.

3.2.5.2 Exception Reviews and Authorizations

All drug bills over $750 and all “Pend” bills require a prior authorization. If authorization is not on file, or attached to the paper bill, deny. If an active authorization is on file, the Contractor will not forward to DCMWC for review. The bill should be processed according to the instructions in the authorization. The pharmacy bill process will require exception reviews/authorizations based upon type of drug (class), specific drug name/NDC, pricing, and other bill attributes. The pharmacy bill process also will provide “lock-in” capability, wherein DOL policy will be supported to ensure specific claimants can only get specific drugs from specific prescribers and pharmacies. Additionally, the pharmacy bill system will support exception processing in the form of overrides consistent with DOL policy.

3.2.6 Drug Pricing

The Contractor will support the use of the MediSpan files as the primary source of drug data and pricing. Pricing for drugs will be implemented according to the three different OWCP programs’ needs. Flat dispensing fees, discounts, co-pays, and/or third-party liabilities will be calculated based on the individual DOL programs. The Contractor will utilize AWP as provided by MediSpan data files. The pricing will be based on AWP-5% plus $4.00 dispensing fee for all drugs and all programs.

3.2.6.1 Pharmaceutical Rebate Program

The purpose and benefit of the pharmaceutical manufacturer rebates includes revenue support to the program. Preferred status of the pharmaceutical product (e.g., Covered versus non-Covered) can generate retrospective discounts toward the program’s cost of the drugs.

3.2.7 Processing Pharmacy Charges Submitted on OWCP 1500 Form

The Contractor will implement a process in which the NDC and quantity submitted on a physician submitted drug bill (OWCP 1500) will be captured at data entry along with the accompanying ‘J’ codes for DCMWC (injection codes J3490 and J8499, and procedures for J8999 and J9999). The billed diagnosis codes will drive Treatment Suite processing. Non-covered diagnoses will not be passed to Treatment Suites.

As part of the bill resolution process, the NDC and quantity submitted will be used to manually obtain an AWP price in the Pharmacy system. The GCN will be used to determine if the NDC is covered or not covered. Once obtained, the Pharmacy price will be manually applied to the professional bill. This ensures pricing is based upon the NDC and specific quantities billed, rather than the J code which is currently set to 'pay as billed'.

There is no fully automated way to process these bills, given the fact that the AWP price needs to be obtained. The Contractor will continue to evaluate this process to streamline it as necessary.

Paper bills submitted by pharmacies will be received in the CBP Central Mailroom and be subjected to the standard Front-End processes. They will be routed via workflow to a queue to be keyed into the pharmacy bill system, and will process and adjudicate just as a POS Pharmacy bill will, subjected to all the Pharmacy edits and pricing logic.

3.2.8 Bills Retention

The Contractor will retain all DOL pharmacy bill data for use in editing EOBs and RVs. All edits or exceptions will be available within the medical bill process for every bill processed. The Contractor will provide access to pharmacy bill data using the medical bill process for specific bill data, including denials (rejections) with reason codes. The Contractor will also provide standard and ad hoc reports via CBP Web Portal.

3.3 Pharmacy Business Process Flow – DCMWC

The following diagram captures the DCMWC Pharmacy Business Process flow.

4 Pharmacy Business Requirements

The following section documents the functional requirements and business rules needed to implement the requirements outlined in Section 19 - Pharmacy of the PWS. For requirements traceability purposes, IDs have been assigned to each functional requirement and business rule. The first two characters of each ID represent the related Program number, (B1 (Core/DFEC), B2 (DEEOIC), B3 (DCMWC), followed by PWS Section, followed by a 3 digit sequentially assigned number within each Build/PWS Section. The Program column indicates whether the requirement/rule is Core (i.e., applies to all programs) or if it is DFEC, DEEOIC, and/or DCMWC specific.

4.1 Functional Requirements

PWS

Req # Functional

Req ID

R0692

R0693

R0694

R0695

R0696

R0697

R0708 R0015

B2-19-BR001

B3-19-BR001

Core

R0700

R0702

R0701

R0703

B3-19-BR002a

B1-19-BR002b

B3-19-BR002b Core

B2-19-BR003

B3-19-BR003

Core

R0706

R0709

R0710

R0711

B2-19-BR007

B3-19-BR007

Core

R0712

R0714

B3-19-BR008

Core

R0716

R0720

R0719

B2-19-BR013

B3-19-BR013

Core

4.2 Business Rules

BR Program

· For batch files, Medicaid/Third Party Biller (TPB) code which is not standard NCPDP will require a special header that includes the TPB code and indicates the alternative party to be billed other than the dispensing pharmacy.

· Process should transmit responses for the POS bills in full compliance with NCPDP messages and codes (including previous transmission formats).

· Process should produce EOB codes directly related to NCPDP and the pharmacy bill process. Error clarification codes should not deviate from the current verbiage to ensure a seamless transition for DFEC clients.

· Process should provide expandable messaging capabilities for duplicate bills and third party denials.

· Process should utilize rejection messaging consistent with NCPDP standards related to specific rejections codes which are relevant to POS responses, avoiding deviations from the current verbiage to ensure a seamless transition for DFEC clients.

· Workflow management processes should include payment and denial policies based on DOL approved edits.

· Existing DOL Pharmacy edits should be reviewed and cross-walked to pharmacy bill process edit, and recommendations should be made where applicable for existing edits.

· Edits that exist in pharmacy bill process but are not in use by DOL should be brought forward for recommendation as well.

· Unique identifier for each pharmacy bill should be produced to easily distinguish the bill as a pharmacy bill, as well as the method in which the pharmacy bill was entered into the system. Paper, Batch, Claimant-submitted (Direct Member Reimbursement [DMR]), and POS entry types are supported in the Claim Indicator Segment of the 6.0 Claims file.

DFEC

· For batch files, Medicaid/Third Party Biller (TPB) code which is not standard NCPDP will require a special header that includes the TPB code and indicates the alternative party to be billed other than the dispensing pharmacy.

· Process should transmit responses for the POS bills in full compliance with NCPDP messages and codes (including previous transmission formats).

· Process should produce EOB codes directly related to NCPDP and pharmacy bill process. Error clarification codes should not deviate from the current verbiage to ensure a seamless transition for OWCP clients.

· Process should provide expandable messaging capabilities for duplicate bills and third party denials.

· Process should utilize rejection messaging consistent with NCPDP standards related to specific rejections codes which are relevant to POS responses, avoiding deviations from the current verbiage to ensure a seamless transition for OWCP clients.

· Workflow management processes should include payment and denial policies based on DOL approved edits.

· Existing DOL Pharmacy edits should be reviewed and cross-walked to the pharmacy bill process edit, and recommendations should be made where applicable for existing edits.

· Edits that exist in the pharmacy bill process but are not in use by DOL should be brought forward for recommendation as well.

· Unique identifier for each pharmacy bill should be produced to easily distinguish the bill as a pharmacy bill, as well as the method in which the pharmacy bill was entered into the system. Paper, Batch, Claimant-submitted (Direct Member Reimbursement [DMR]), and POS entry types are supported in the Claim Indicator Segment of the 6.0 Claims file.

DEEOIC

· For batch files, Medicaid/Third Party Biller (TPB) code which is not standard NCPDP will require a special header that includes the TPB code and indicates the alternative party to be billed other than the dispensing pharmacy.

· Process should transmit responses for the POS bills in full compliance with NCPDP messages and codes (including previous transmission formats).

· Process should produce EOB codes directly related to NCPDP and the pharmacy bill process. Error clarification codes should not deviate from the current verbiage to ensure a seamless transition for OWCP clients.

· Process should provide expandable messaging capabilities for duplicate bills and third party denials.

· Process should utilize rejection messaging consistent with NCPDP standards related to specific rejections codes which are relevant to POS responses, avoiding deviations from the current verbiage to ensure a seamless transition for OWCP clients.

· Workflow management processes should include payment and denial policies based on DOL approved edits.

· Existing DOL Pharmacy edits should be reviewed and cross-walked to the pharmacy bill process edit, and recommendations should be made where applicable for existing edits.

· Edits that exist in the pharmacy bill process but are not in use by DOL should be brought forward for recommendation as well.

· Unique identifier for each pharmacy bill should be produced to easily distinguish the bill as a pharmacy bill, as well as the method in which the pharmacy bill was entered into the system. Paper, Batch, Claimant-submitted (Direct Member Reimbursement [DMR]), and POS entry types are supported in the Claim Indicator Segment of the 6.0 Claims file.

DCMWC

· The pricing should be based on AWP-5% plus $4.00 dispensing fee for all drugs and all programs.

Core

The physician submitted bill will process through Treatment Suites following the 1500 path, checking billed diagnosis codes against the claimant's accepted condition, and ensuring the billed procedure (in this case the 'J' code) is covered. The 'J' code will be a covered service in Treatment Suites, but will have a Control Code to set to Review/Suspend, causing the bill to suspend.

Core

DFEC

· The claimant's accepted condition will not be used as entry to Treatment suites for DCMWC. The first billed diagnosis code will drive Treatment Suite processing. Non-covered diagnoses will not be passed to Treatment Suites.

DCMWC

There is no fully automated way to process these bills, given the fact that the AWP price needs to be obtained and the Therapeutic class needs to be checked to ensure it is covered for the claimant's accepted condition. The Contractor will continue to evaluate this process to streamline it as necessary Core

DFEC

· Out-of-cycle reversals will automatically create an AR1, create a debt in the medical bill process “Payee Balance Credit,” and send the debt to the IFECs system.

· All credits and reversals are anticipated to be generated by the pharmacy through an NCPDP reversal transaction.

· The Contractor should provide recommendations for future enhancements to the process to be more in line with industry practices.

DFEC

· Out-of-cycle reversals will automatically create an AR1 and create a debt in the medical bill process “Payee Balance Credit.”

· All credits and reversals are anticipated to be generated by the pharmacy through an NCPDP reversal transaction.

· The Contractor should provide recommendations for future enhancements to the process to be more in line with industry practices.

DEEOIC

· Out-of-cycle reversals will automatically create an AR1 and create a debt in the medical bill process “Payee Balance Credit.”

· All credits and reversals are anticipated to be generated by the pharmacy through an NCPDP reversal transaction.

· The Contractor should provide recommendations for future enhancements to the process to be more in line with industry practices.

DCMWC

Core