Incorrect Billing on Nayzilam® and Valtoco® Can Cost You
Nayzilam® and Valtoco® are indicated for the short-term treatment of seizure clusters that are distinct from a patient’s usual seizure pattern in patients with epilepsy.
Entries by Jennifer Ottman, CPhT
Respiratory Syncytial Virus (RSV) – What You Need to Know
There are currently three FDA-approved Respiratory Syncytial Virus (RSV) vaccines available for individuals at risk of severe illness from a respiratory virus. Please review the chart for helpful billing tips and the additional information below as to which RSV vaccine is appropriate to give to an eligible individual.
Medicare Part A vs Part D Billing Risks – How to Protect Your Claims
Pharmacies continue to receive PBM audit notices for claim recoupments where the [allegedly] improper Medicare coverage was billed. Medicare Part A helps cover hospital, skilled nursing facility (SNF), and hospice care stays. Medicare coverage status is typically linked to the patient’s admission and discharge dates from a Part A stay. When a patient is covered […]
Updated Form Expiration 12/31/2027 – Medicare Drug Coverage and Your Rights Notice
The CMS-10147 Form, also known as the Medicare Drug Coverage and Your Rights Notice, must be distributed to Medicare Part D beneficiaries when a prescription is not covered at the point-of-sale. This notice informs beneficiaries about their right to contact their Part D plan to request a coverage determination, including an exception. The distribution of the […]
Proof of Patient Counseling Required!
Pharmacies are familiar with submitting copies of prescriptions, signature logs and proof of copay collection upon an audit request, but do you have documented proof of the offer to counsel? While the patient can accept or refuse counseling, it must be documented for Medicaid patients. PAAS National®® analysts often see pharmacies with these requests during Medicaid […]
PBM Prescription Validation Requests – What Are They Looking At Now?
The July 2024 PAAS National®® Newsline article, What’s New with Prescription Validation Requests in 2024? compared the top five drugs targeted in the first six months of 2024. The chart below shows the top drugs picked for claim reviews in the second half of 2024, and a recap of the first half of 2024.
Optimizing Prescriber Statements: Best Practices and Tips
Prescriber statements have become one of the most valuable tools a pharmacy can use when needing to appeal claims found to be discrepant for a variety of reasons. They commonly take the form of a letter written by the prescriber to the PBM confirming, clarifying, or validating a prescription filled by your pharmacy. While every […]
Adjusting Quantity or Days’ Supply Disproportionately Will Cost You!
PAAS National®® wants to emphasize the importance of submitting the correct days’ supply on claims. We see many audit results that could have been avoided had the pharmacy addressed the initial rejection and not bypassed the plan limit. A prevention strategy is important because these discrepancies are often difficult to appeal successfully. Pharmacy employees should […]
A New Way to Administer Epinephrine – Introducing neffy®
ARS Pharmaceuticals Operations has recently introduced neffy® 2 mg, the first and only FDA-approved needle-free way to administer epinephrine. neffy® is a nasal spray used for emergency treatment of severe allergic reactions in adult and pediatric patients who weigh at least 66 pounds (30 kg). Per DailyMed, “the recommended dosage of neffy® is one spray […]
New Tool on PAAS Portal – Exceeding Days’ Supply Plan Limits for Unbreakable Packages
PAAS National® is continuously updating and creating new tools to help our members address common audit recoupment issues.
