Whi pharmacy manual

WHP Health Initiatives, Inc.
2275 Half Day Road, Suite 250
Bannockburn, IL 60015
WHP Health Initiatives, Inc. ("WHI") is pleased to welcome you to our network of participating pharmacies.
We look forward to working with you to provide accessible, cost-effective, high quality pharmacy services for our clients and their members.
TABLE OF CONTENTS
THE IDENTIFICATION CARD. 3 DRUG PROGRAM SPECIFICATIONS, GENERALBenefit Design. 4Dispensing Limitations. 4Reimbursements . 4Inquiries. 4Coverage . 5Signature Log. 5 GENERAL CLAIM INFORMATIONSubmission of Prescription Claims. 6Point-of-Sale. 6Universal Claim Forms . 7Processing of Prescription Claim Forms. 8Reports to Pharmacies. 8Pricing . 8Questions Regarding Claims Submission. 8 SAMPLE FORMSUniversal Claim Form Explained.9-10 TELEPHONE NUMBERS . 11 VII. ADDING OR DELETING A PHARMACY LOCATION. 12 LIST OF FIGURES AND TABLES
WHI Identification Card. 3 Universal Claim Form. 9 Basic Pharmacy Information. 12 This manual is intended to serve as a guide to assist your pharmacy staff by providinginformation regarding the procedures and policies of WHI.
As you read through this manual you will find:• Sample drug program specifications • General information • Information to aid pharmacies in submitting prescription claims On-line claims adjudication reflects the most current benefits and takes precedenceover any printed information.
We hope that your day-to-day questions concerning WHI pharmacy programs areadequately addressed in this manual. If you have additional questions or if additionalinformation is needed, the appropriate telephone numbers are on page 9.
II. THE IDENTIFICATION CARD II. THE IDENTIFICATION CARD
WHI members are provided with an identification card. Members are instructed topresent their ID card when obtaining a prescription from a network pharmacy. Whenfiling a claim for services, it is important that you ask to see the ID card and the name ofthe member who will be using the prescription. If no ID card is presented and eligibilitycannot be confirmed on-line, the pharmacy may collect its usual and customary retailprice.
Network pharmacies will provide services to eligible members in a timely manner, asprovided to other customers, and shall have pharmacy services available for a minimumof eight hours a day, six days a week.
Figure 1. WHI Identification Card Information on the WHI Identification Card (see Figure 1)
required in filing a claim:
• Cardholder Name
The subscriber name associated with the cardholder ID number.
• Cardholder ID Number
The subscriber identification number. This will usually be either a nine digit numberor nine digit number with a two digit suffix. (Patient's birth date must also besubmitted with claim.) • Group Number
A six digit alpha/numeric code assigned to the plan must be submitted with eachclaim.
III. DRUG PROGRAM SPECIFICATIONS, GENERAL (CAN VARY BY PLAN) III. DRUG PROGRAM SPECIFICATIONS, GENERAL
(CAN VARY BY PLAN)
A. BENEFIT DESIGN
1. Covered Medications:
a) All federal legend drugs (drugs approved by the FDA unless listed in "Exclusions") b) Insulinc) Compound medications containing at least one legend drugd) Injectables a) Over-the-counter drugs, except as listed aboveb) Lifestyle drugsc) Therapeutic devices or appliances B. DISPENSING LIMITATIONS
1. Participating pharmacies should exercise sound professional judgment regarding drug dispensing practices and act in accordance with all stateand federal regulations.
2. Pharmacist shall dispense the quantity of medication as prescribed NOT TO EXCEED the plan maximum benefit.
1. Drug Cost:
Based on discounted AWP or MAC 2. Professional Fee:
Brand: per agreementGeneric: per agreement NOTE: If the amount of the claim is less than the copayment charge,
pharmacy shall collect from the member the lesser of pharmacy'susual and customary charge for the prescription or the member'scopay.
Claim Status: Any questions regarding claims status should be directed to
our Member Services Department, available toll-free at 1-800-207-2568.
Please identify your pharmacy as a provider for WHI and have your NCPDP
number available.
2. Member Eligibility: Any questions regarding member eligibility should be
directed to our Member Services Department, available toll-free at 1-800-207-2568. Member identification number and group information should beavailable.
III. DRUG PROGRAM SPECIFICATIONS, GENERAL (CAN VARY BY PLAN) E. COVERAGE
A pharmacist can verify a member's coverage by submitting the informationnoted on the Membership ID Card. If an "invalid" response is received, pleasecheck that all submitted information exactly matches the elements on the IDcard.
F. SIGNATURE LOG
Pharmacy shall maintain a signature log at each location listing the Plan Name,Prescription Number, and date of receipt, and require an eligible member orrepresentative who receives a covered drug to sign the log.
IV. GENERAL CLAIM INFORMATION IV. GENERAL CLAIM INFORMATION
A. SUBMISSION OF PRESCRIPTION CLAIMS
1. Pharmacies are required to submit a billing record of service for all covered prescriptions provided to a member. This includes prescriptions for whichthe usual and customary charge is less than the copayment and noreimbursement is due to the pharmacy.
2. Effective no later than October 16, 2003, Pharmacies must submit claims via electronic data interchange using NCPDP Version 5.1, as required underHIPAA. Prior to the conversion to NCPDP Version 5.1, pharmacies mustsubmit electronic claims using NCPDP Version 3.2A.
3. All claims received on-line by the last working day of the semi-monthly processing cycle will be processed in the current payment cycle. Checkswill be mailed after the release of funds by the plan sponsor.
4. In the event of prolonged system downtime, pharmacy may submit claims within 60 days of service via either electronic transmission or UniversalClaim Form (UCF).
1. Pharmacy Vendor and Point-of-Sale Devices: Point-of-sale claims can be
submitted to WHI through a pharmacy computer system or point-of-saledevice. Please contact your pharmacy system or point-of-sale devicevendor if you have any questions about how to submit claims.
2. Phone Number: Please contact the communication network vendor to
obtain the phone number that allows you to access the processor andsubmit claims.
3. Claims Submission: WHI will identify whether a claim has been
accepted or rejected. If the claim is accepted, WHI will identify the amountpaid and the copay to collect from the member. WHI will provide additionalinformative messages (e.g., the quantity allowed is less than submitted). Ifthe claim is rejected, WHI will identify the reason(s) why the claim wasrejected.
4. Bin Number and Carrier ID: When submitting claims through point-of-sale,
you are required to submit a Bin number and Carrier ID. The Bin number is603286; the Carrier ID (PCN) for WHI is 01410000. This number must besubmitted with every claim. Your system or device vendor can tell you howto input this ID.
5. Reversals: If you need to resubmit a claim previously accepted through
point-of-sale, you must first submit a reversal. You must also submit areversal when a member fails to pick up a filled prescription within ten days.
Please refer to your system documentation or vendor for information aboutsubmitting reversals.
IV. GENERAL CLAIM INFORMATION a) If your pharmacy system or point-of-sale device is unable to make a connection with the claim processor's computer system, contact yourcommunication network vendor or switch.
b) If a claim is rejected and you do not understand the reason provided or if you have a question about the reimbursement for a claim, contact theclaim processor through the network Member Services Department (1-800-207-2568). Please have your NCPDP number and prescriptionnumber available when you call.
c) If you have a question about pharmacy, prescriber, or member eligibility, contact the network Member Services Department (1-800-207-2568).
STANDARD UNIVERSAL CLAIM FORM (UCF)
1. Types of Forms
a) Handwritten - when the form is completed by hand, the last copy is sent to the claim processor.
b) Computer generated - when the form is computer generated: Submit only the original (top) copy.
The continuous form paper used by computers when printing UCFclaims should be separated (burst) and the tractor strips must beremoved from the edges prior to sending to the claim processor.
You may choose to have the member sign a prescription log. Thisshould be noted with "Signature on File" in the appropriate spaceon the UCF.
2. Fees - there may be a fee reduction per claim for processing Universal
Claim Forms.
3. Submitting claims for processing
a) All UCFs must be legible, accurate, and complete. Please type or
neatly print all the UCF information.
b) Claims and corrections to prior claims must be forwarded to WHI via first class mail within 60 days of original service date. To assureproper handling the following address should be used when mailingclaims information: WHP Health Initiatives, Inc.
Claims DepartmentP.O. Box 545Deerfield, IL 60015 NOTE: Claims information submitted in any manner other than the above
procedure may be subject to loss or lengthy processing delays.
IV. GENERAL CLAIM INFORMATION PROCESSING OF PRESCRIPTION CLAIM FORMS
1. Each individual claim will be processed as received by the claim processor.
Extensive edit checks are made to assure proper reimbursement. Claimscontaining one or more fatal errors will be rejected. Pharmacy mayresubmit claims found to be in error within 60 days of original service date tothe claim processor for further processing.
2. Adjustments to paid or denied claims are possible. The pharmacy should submit to WHI documentation supporting the pharmacy's request for acorrection, and a copy of the claim processor's reconciliation highlighting theclaims or claims for which you are requesting adjustments.
REPORTS TO PHARMACIES
1. Checks will be mailed to pharmacies twice a month. The Pharmacy
Reconciliation Report will provide an accounting of all claims submitted tothe claim processor during the current cycle, and will provide totals forreconciliation of the check amount.
2. Following is a list of the items that WHI will produce and forward directly to pharmacies:• Pharmacy Reconciliation Report • ChecksThese items are mailed in accordance with the specifications cited in eachsponsor's individual contract.
PRICING: Each submitted claim will be priced using the specific guidelines
established by the Plan Sponsor. The source of AWP prices is First Data
Bank's Blue Book. Prices are effective on the date the prescription was filled.
QUESTIONS REGARDING CLAIMS SUBMISSION: Please direct all inquiries regarding
claims to:
WHP Health Initiatives, Inc.
Claims Department
P.O. Box 545
Deerfield, IL 60015
1-800-207-2568
SAMPLE Universal Claim Form (UCF) Explained
(see Figure 2)
Note: Upon release, new versions will be accepted.
Group No. - group number designated on the ID card.
Card Holder ID No. - subscriber ID number from the Prescription Drug
Benefit Card.
IMPORTANT: Please include the complete ID number, which
may include a suffix at the end of the subscriber's ID.
Card Holder Name - The member's name from the membership ID card.
Name - The name of the pharmacy submitting the claim.
Pharmacy No. - NCPDP number of the pharmacy submitting the claim.
If you do not know your NCPDP number, it can be obtained by calling the
office of the National Council of Prescription Drug Programs at 480-477-
1000.
Patient Name - The patient's full name should correspond to ID card and
prescription order.
Date of Birth - Birth date of patient (MMDDYYYY).
Sex - Place an "X" in the appropriate box to identify patient's sex.
Relationship to Cardholder - an "X" in the Card Holder, Child, Spouse,
or other box as appropriate.
Date Rx(s) Written - This is the month, day, and year the prescription(s)
was written (MMDDYYYY).
FIGURE 2. UNIVERSAL CLAIM FORM Date Rx(s) Filled - This is the month, day, and year the prescription(s) was
filled (MMDDYYYY).
Rx Number - prescription number consisting of up to seven digits.
NEW/REFILL - Place a "N" in the box if this pertains to an original
prescription, or "R" in the box if it is a refill.
Metric Quantity - number of tablets, capsules, etc., dispensed.
a) When liquids are dispensed, use ml or cc and decimals if appropriate
(i.e., 2.5).
b) When original packages (ointments, drops, etc.) are dispensed, use
metric units dispensed such as grams or cc. For example, Aristocort Cr _
oz. should show "15" - referring to the number of grams.
c) Do not write the metric form being used (i.e., ml or cc) on the UCF.
Days Supply - The number of days the medication will last the patient
when taken according to directions. If the days supply is not applicable or
not known, enter "1".
National Drug Code - The National Drug Code for the drug being
dispensed. If the drug is a compound, enter the NDC of the most
expensive legend ingredient, and detail the compound on the back of each
claim form. Include the NDC number of each legend drug in the
compound.
Prescriber Identification - the prescriber's ID number. A valid DEA number
must be submitted for each claim. If the DEA number is not available,
please provide the prescriber's name.
DAW (dispensed as written) – Standard NCPDP Codes are:
0 = No product selection indicated1 = Substitution not allowed by prescriber2 = Substitution allowed - patient requested product dispensed3 = Substitution allowed - pharmacist selected product dispensed4 = Substitution allowed - generic drug not in stock5 = Substitution allowed - brand drug dispensed as a generic6 = Override7 = Substitution not allowed - brand drug mandated by law8 = Substitution allowed - generic drug not available in marketplace9 = Other Ingr. Cost - The billed amount for the dispensed quantity of drug only
($$$.¢¢).
Disp. Fee (optional) - professional fee charged for dispensing the drug
($$$.¢¢).
Tax - The appropriate City, County and State tax, where applicable.
Total price (required) - total of the ingredient cost, dispensing fee, and tax
($$$.¢¢), or the usual and customary retail, whichever is less.
DED. Amt. (Optional) - The Copay amount collected ($$$.¢¢).
Bal - The total billed amount ($$$.¢¢).
VI. TELEPHONE NUMBERS VI. TELEPHONE NUMBERS - Major holidays excluded
Member Services Department: 1-800-207-2568
(available 24 hours Sunday through Saturday)
VII. ADDING OR DELETING A PHARMACY LOCATION VII. ADDING OR DELETING A PHARMACY LOCATION
A. ADDING A PHARMACY LOCATION
To enroll new pharmacies under an existing agreement or to ensure transfer ofprovider information for relocated pharmacies with new NCPDP numbers, sendthe information in Table 1 (below) in a timely manner to WHI.
Send Information to:WHIProvider Relations Department2275 Half Day Road – Suite 250Bannockburn, IL 60015FAX No: (847) 572-4128 TYPE OF FIELD
Chain or Store NAME Store NUMBER (if any) State (2-letter abbrev.) 24-Hour Location? Tax ID Number(FEIN) State License Number Table 1: Basic Pharmacy Information WHI will automatically add new or relocated pharmacies within 48 hours ofreceipt of this information on a routine basis. Please be proactive in providingthis information regularly to ensure smooth operation at your store and goodcustomer service.
B. DELETING A PHARMACY
If a pharmacy is no longer in operation or the NCPDP number is no longeractive, please notify WHI as soon as possible to ensure accuracy of claims dataand provider information to customers.

Source: http://www.walgreenshealth.com/common/pdf/PharmacyManual.pdf