For those of you who still have questions about Billing Drugs and Supplies to Medi-Cal:

For dates of service beginning April 1, 2009, Medi-Cal has made changes for billing drugs and supplies. Drug claims must contain an NDC, NDC Units Qualifier, NDC Units, HCPC and 340B pricing modifier where applicable. Supply claims must contain a UPN (Universal Product Number) and UPN Qualifier. A spreadsheet that lists the supply item, UPN and UPN qualifier is available on Medi-Cal’s website. Significant changes had to be made to CPR+ to accommodate their requirements, mostly to the creation of the 837P claim file and the printed CMS1500.

In CPR+ v8.1e (and beyond) there are new fields in Inventory on the Medi-Cal tab. (This tab will only display when at least one company state is California.)

Drugs:

• Modifier = UD: This is to indicate if the item is a 340B Drug Item.

Supplies: 

• UPN Qualifier = As dictated by the Medi-Cal spreadsheet.
• UPN = As dictated by the Medi-Cal spreadsheet.
• Send Pricing = Required if pricing is not present on the Medi-Cal spreadsheet.

New Fields in Insurance Company Setup:
Setup Options tab > 21+:

(Note: Option numbers listed are based on CPR+v8.1. Customers using CPR+v8.2 will see slightly different numbering, but the titles will remain the same.)

#27: Use Medi-Cal Modifier on Invoice Line Items. This will populate the UD or value entered from the Modifier field in Inventory onto the Line Item of the invoice.

#28: Use Medi-Cal Formatting for Supplemental Info Line on CMS/UB04. Medi-Cal requires the NDC qualifier and Units to print at the start of box 24D and use zeros to fill spaces. The NDC qualifier, NDC, NDC Units Qualifier, and NDC Units will print in the box 43 (description) of the UB04. The drug modifier will print directly after the HCPC in box 44. This option will ensure these items print accordingly for each invoice type.

#29: Print Medi-Cal Itemized Listing. (HCFA/CMS1500 Invoices Only) Will print the Medi-Cal Itemized Listing report. This is the same report that prints with the 30-1.

Electronic Setup (F8) checkboxes:

• Send UPN for Supplies (Medi-Cal) Check for both electronic and paper invoice types. (Since this box is only available for electronic invoice types, the invoice type will need to be Electronic Medical. Check the box, then change the invoice type back to CMS1500.)
• Exclude 2010AA REF G5 Check for sending directly to Medi-Cal.
• Exclude 2010BB REF FY Check for sending directly to Medi-Cal.

When the 837 claim file is created, the above loops / segments will not be included.

Advanced Options (F9)

Click on the Payor requires direct submission of claims checkbox – this will open up the fields on the left side of the page.

Populate only the following fields:

• Interchange Sender ID: Medi-Cal Electronic Submitter ID (3 characters)
• Interchange Receiver ID: 610442
• Application Sender’s Code: Medi-Cal Electronic Submitter ID (3 characters)
• Application Receiver’s Code: 610442
• Submitter ID:Medi-Cal Electronic Submitter ID (3 characters)
• Receiver’s Primary ID Number: 610442

Electronic claims will go to the WebMD Medical electronic claims queue. Filter by Payor and select the Medi-Cal payor PRIOR to selecting claims to transmit and building the 837P claim file. Once the Transmit Menu appears, the claim file will then need to be uploaded to Medi-Cal’s website.

If you have questions not answered here, please contact our Customer Support Department for more information.

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Are you filling some prescriptions and not getting paid for them? CPR+ has very good integration available between prescriptions and authorizations. If you are making use of this integration, your pharmacists receive a warning when they try to fill a prescription where the required authorization is missing or expired.

Why would pharmacists dispense a prescription when they have been warned that a required authorization is missing or expired? Perhaps it’s the weekend and the payor is closed. Perhaps the authorization process is lengthy and the need for the drug is urgent. CPR+ does not prevent the pharmacist from dispensing the prescription, but it does create a log entry when a prescription is filled after an authorization warning has been displayed. The Bypassed Authorizations report allows you to see which prescriptions have been dispensed without an authorization, so you can get the authorization in place before you send out an invoice.

To run this report, from the Main Menu select Reports (4) > Billing Reports (4) > Misc. Billing Reports (7) > Bypassed Authorizations (5). Select the date range. Run this report every Monday to see what authorizations you need to chase down from the last week.

If you need training on how to integrate orders and authorizations, contact Kim Carlsen at 866-277-4876 to schedule some time with a trainer.

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As the Editor of this newsletter, I have the privilege of receiving phone calls and emails from customers who wish to express appreciation for various articles that made their job a little easier. Hearing that our publication makes a difference in your day makes my duties as Editor that much more enjoyable. We strive to pack every issue with training-related, meaningful content that our customers can use. That said, we try to have a little fun along the way, with employee bio’s, and an occasional cartoon, etc. One of the most popular of these add-on articles is the monthly customer anniversary announcement.

It started in June 2008, and has appeared in the Weekly Infusion every month since then… or so I thought! Last week, I received an email from Lavona Simmons of Integrated Care Systems, Visalia, CA. Lavona was wondering why her company has never been mentioned. I did a little research and quickly discovered that I somehow skipped the anniversary announcement last October. Eee gads! (Hmmm… I wonder what we were doing in early October last year… oh, that little User Conference thingy…) Unfortunately, we can't mention every year for every customer, but we try to list every customer celebrating one, five, ten and fifteen years with our company.

And so, with my most sincere apologies and without further ado, and hopefully better late than never: Thank you to the following CPR+ Customers for being with us for one, five or ten years (or so.)

Ten Years, Eight Months and Four Days:
Vital Systems of Oklahoma
(Mustang, OK)

Five Years, Seven Months, Twenty-Six Days:
Fairlane Pharmacy Services
(Southfield, MI)

Five Years, Seven Months, Twenty-Four Days:
Therapoint
(Dunmore, PA)

Five Years, Seven Months, Twelve Days:
Option Care of the Quad Cities
(Moline, IL)

Five Years, Seven Months, Nine Days:
US Bioservices
(Addison, TX)

One Year, Seven Months, Eighteen Days:
Integrated Care Systems
(Visalia, CA)
             and
Complete Infusion Care
(Los Angeles, CA)

One Year, Seven Months, Nine Days:
Southwest Physical Therapy
& Rehabilitation
(Port Charlotte, FL)

Thank you for being GREAT customers. And thank you Lavona!

p.s. Bambi - Stay Tuned...

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