Agencies
Services
Provider Notice Issued 02/07/2017
Pharmacy Pilot Testing of Pharmacy Benefits Management System (PBMS)
Date: February 7, 2017
To: Participating Pharmacies
Re: Pharmacy Pilot Testing of Pharmacy Benefits Management System (PBMS)
This notice informs providers that the Illinois Department of Healthcare and Family Services (HFS) in conjunction with Change Healthcare (CH) will be pilot testing the new Point of Sale (POS) Pharmacy claims processing system. As described in previous Provider Notices, the Pharmacy Benefits Management System (PBMS) will allow for faster and more efficient processing of pharmacy claims billed fee-for-service.
Pilot testing for the new PBMS system will begin February 17, 2017 and continue through March 13, 2017. Pharmacies interested in participating in pilot testing should complete the registration form that will be distributed in a subsequent provider notice.
The updated payor sheet can be found on the Department’s Payor Sheet webpage. Specific programming instructions for submittal of NCPDP D.0 format transactions are contained in this draft.
The chart below explains changes to the payor sheet as a result of implementation of the PBMS. Guidance for all of the POS changes are included within the payor sheets.
Field # |
Field Name |
Explanation of Change |
438-E3 |
Incentive Amount Submitted |
Claims for vaccine administration fee should no longer be submitted using the S1, S2 or S3 transaction. In the new POS system, claims for vaccines will be required to be submitted using the B1, B2 or B3 transaction. The vaccine administration fee should be submitted in this field. |
440-E5 |
Professional Service Code |
Submit the professional service code “MA” when submitting administration fee. |
420-DK |
Submission Clarification Code |
05=Therapy Change added. |
308-C8 |
Other Coverage Code |
1=No Other Coverage added. 8=Copay only deleted. |
341-HB 342-HC 431-DV 353-NR
351-NP
352-NQ |
Other Payer Amount Paid Count Other Payer Amount PAID Qualifier Other Payer Amount Paid (OPAP) Other Payer -Patient Responsibility Amount Count Other Payer -Patient Responsibility Amount Qualifier Other Payer -Patient Responsibility Amount (OPPRA) |
The new POS system will use the NCPDP COB 3 scenario which utilizes the fields listed in the “Field Name” column to the left.
|
427-DR 498-PM 419-DJ |
Prescriber last name Prescriber phone number Prescription Origin Code |
Required fields. |
462-EV |
Prior Authorization (PA) Number Submitted |
Submit the PA Number for the payor defined situation identified in (“1”) in field 461-EU (Prior Authorization Type Code). Submit the value “72” = 72 hour emergency supply when 461-EU value = “2”. |
344-HF 345-HG |
Quantity Intended to be Dispensed Days Supply Intended to be Dispensed |
Required for the partial fill of a prescription or for a completion fill when 345-HG/344-HF field is completed. |
General Information and Guidance
File Transmission
Refer to the NCPDP Telecommunication Standard Implementation Guide Version D.0 (pdf) for the structure and syntax of transaction(s) for file transmission.
File Segment
Each segment is listed as mandatory, situational or optional for a given transaction in the NCPDP Telecommunication Standard Implementation Guide (pdf). If a segment is labeled as mandatory, that segment must be sent. If the segment is labeled situational, please follow the guidelines in the “Payer Situation” column.
Questions regarding this notice should be sent to: PBA_POSTechSupport@changehealthcare.com or by calling 877-553-8455.
Felicia F. Norwood
Director