In general, origin code errors are educational with a few exceptions. Humana will charge a $5 penalty fee for an incorrect origin code being billed when discovered on audit. This will be for the original claim and each refill also billed incorrectly (e.g., original fill plus 11 refills = $60 recoupment). If a telephone order is sent in for audit when billed with a different origin code, some auditors will assume the pharmacy could not find the “original” prescription and simply wrote one up. Auditors will mark the claim discrepant until the pharmacy can produce the prescription with the correct origin code or obtain a prescriber statement. Additionally, with Medicare Part D now
requiring electronic prescribing of controlled substances (EPCS), CMS will rely on the origin code (initiated by the pharmacy) in the Prescription Drug Event (PDE) data to determine if physicians are adhering to the requirements.
NCPDP defines origin code values as follows:
| CODE |
DESCRIPTION |
| 0 |
Not Known |
| 1 |
Written – Prescription obtained via paper. |
| 2 |
Telephone – Prescription obtained via oral instructions or interactive voice response using a phone. |
| 3 |
Electronic – Prescription obtained via SCRIPT or HL7 Standard transactions, or electronically within closed systems. |
| 4 |
Facsimile – Prescription obtained via transmission using a fax machine. |
| 5 |
Pharmacy – This value is used to cover any situation where a new Rx number needs to be created from an existing valid prescription such as traditional transfers, intrachain transfers, file buys, software upgrades/migrations, and any reason necessary to “give it a new number.” This value is also the appropriate value for “Pharmacy dispensing” when applicable such as BTC (behind the counter), Plan B, established protocols, pharmacists authority to prescribe etc. |
Here are questions PAAS National® has frequently answered:
Question 1: If a pharmacy calls a prescriber to clarify a written prescription, or a change is needed, does the origin code become a “2” for Telephone?
Answer: No, the NCPDP Telecommunication FAQ section 3.1.5.3 states, “Because the prescription was received via written form the Prescription Origin Code is 1 and will remain a 1 throughout the life of the prescription number.” The same would be true if received by any other origin.
Question 2: If a prescriber sends a prescription electronically, but the pharmacy is not electronically-prescribing enabled or if there is a transmission error, and the intermediary drops the prescription to a fax, what origin code is used?
Answer: Per NCPDP, “Because the prescription was received at the pharmacy via fax the Prescription Origin Code is 4 and will remain a 4 throughout the life of the prescription number.”
Question 3: What origin code is used for a standard written authorization or protocol for services and products like, vaccines or Narcan®?
Answer: The NCPDP definition for protocols is Prescription Origin Code of “5” since the prescription is created by the pharmacy in these cases.
PAAS Tips:
- Always bill the correct origin code to avoid potential recoupment.
- The origin code remains the same through the life of the prescription.
- Too many incorrect origin code discrepancies can lead to more frequent audits.
- See the NCPCP Telecommunication Version D and Above Questions, Answers and Editorial Updates document for more information and scenarios.
Levemir® FlexPen® is Replacing the Levemir® FlexTouch®
Novo Nordisk® discontinued manufacturing the Levemir® FlexTouch® in early February 2023. The FlexTouch® will be distributed until stock is depleted and is being replaced with the FlexPen®. Please see the charts below for changes between the FlexTouch® and the FlexPen®.
PAAS Tips:
To Sign, or Not to Sign, the OptumRx® Recoupment Waiver … That Is the Question
If your pharmacy has recently been through an OptumRx® desk audit, you may have come across the OptumRx Provider Intent Form – Recoupment Waiver. This one-page form accompanies initial audit results and if signed, gives OptumRx® even greater power over the pharmacy. A signature on the form indicates the following:
There is no apparent benefit to the pharmacy by signing this form. Additionally, signing and agreeing to the preliminary audit findings could be construed as the pharmacy’s admission of wrongdoing. Only OptumRx® would benefit from this waiver and PAAS National® does not feel it is in the best interest of pharmacies to sign.
If you have additional questions or concerns regarding audit preparation, the audit appeal process, or safe billing and filling strategies, the PAAS team is here to guide you. Give us a call (608) 873-1342, email info@paasnational.com or submit a question online through the PAAS Member Portal.
First Step in Getting Help with an Audit
Oh no! You just received an audit, now what? Your first step is to get the audit notice to PAAS National® – the sooner that we are part of your team, the more benefit we can bring. Our all-inclusive membership means there are no hidden fees or limits to the audit assistance you can receive.
Make PAAS part of your audit process, every time. Review the 4 Steps to Using your PAAS Audit Assistance on the PAAS Member Portal for audit assistance members under Proactive Tips.
One of the best ways to get started is to create a workflow process when audits are received. Too many dollars are lost to PBMs due to missed deadlines or incomplete documentation – don’t let this happen to you. By putting a few simple steps in place, you can avoid costly mistakes in the future.
PAAS Tips:
Are Your Delivery/Signature Logs PBM Compliant for 2023?
A common component of a pharmacy audit request is the delivery/signature log. Delivery/signature logs are used to prove the patient received their medication and that they received it within the PBM return to stock timeframe. PAAS Audit Assistance members can refer to the PBM Return to Stock Chart on the PAAS National® Member Portal for a list of the major PBMs and their return to stock time frame allowances.
PAAS often sees delivery/signature logs flagged for having a pre-printed delivery date. Several PBMs do not accept these logs because they may not represent the actual delivery date. Here is an example:
Recent Elixir results state, per the Elixir pharmacy manual, “Receipt submitted states “Delivery.” Unless the prescription delivery is through a common courier, an electronic or manual signature should be recorded at time of delivery by the member or designated member representative. For deliveries, the date delivered cannot be pre-printed by the pharmacy.”
Some software systems allow a pharmacy to “scan out” a prescription and flag it for delivery. The driver can take this date/time stamped point of sale receipt (that notates delivery) to the patient’s address and have them sign. PAAS also sees many LTC facility delivery manifests containing a pre-printed date on the document. An auditor is not going to accept/assume the delivery took place the same day as the pre-printed date and will likely flag these logs as invalid. The pharmacy needs to provide documentation of when the delivery took place by having the patient, or representative, date their signature upon delivery. Consider adding a blank line for a handwritten date next to the signature line that can be completed upon delivery.
PAAS Tips:
Process for Dealing with a Patient HIPAA Complaint
Anyone can file a complaint if they feel their rights under the HIPAA Privacy, Security, or Breach Rules have been violated. They can file a complaint with the covered entity or business associate involved, or with the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (the OCR). The HHS.gov website has a full page dedicated to filing a complaint and is one of the first listings to appear if someone performs an internet search for “filing a HIPAA complaint”.
Appropriately handling the patient’s complaint by taking it seriously, investigating, and responding may help decrease the risk of the OCR launching an investigation into your pharmacy. Additionally, if an investigation does occur, following the steps listed below can help ensure that your pharmacy would have all the required information documented to prove you handled the situation pursuant to the HIPAA Rules.
Steps to follow if a patient believes their HIPAA rights have been violated:
If HIPAA Rule violations are found during an OCR investigation, the pharmacy can be forced to pay civil money penalties and can even be held accountable for an employee’s failure to adhere to company HIPAA policies and procedures. Additionally, individuals accessing or utilizing protected health information inappropriately can be charged civil money penalties or even face criminal charges (and jail time!) for violating the HIPAA Rules.
PAAS Tips:
Express Scripts Validating 340B Claim Eligibility
PAAS continues to see members receiving emails from Express Scripts (ESI) requesting pharmacies to “Please Review Your 340B Eligible Claims”. ESI’s goal is to verify manufacturer rebate eligibility and states “your claims reimbursement, network participation, and network status are not affected by a claim’s status as 340B-eligible or whether you respond”.
While seemingly haphazard in claim selection and frequency, Express Scripts is attempting to identify a subset of claim(s) that were initially processed as not 340B-eligible, but in actuality may have been dispensed/reimbursed as 340B. From communication with members, PAAS can see the algorithm ESI is using is far from perfect. Conjecture leads us to believe they are using the HRSA OPAIS website to look at providers and pharmacies, then targeting high dollar brand medications.
If the pharmacy agrees that the claims were 340B claims, no action is required and Express Scripts will reprocess the claim(s). If the pharmacy believes the claims were correctly adjudicated as non-340B eligible, the pharmacy should respond within 10 business days by emailing 340bclaims@express-scripts.com to refute Express Script’s conclusion.
PAAS Tips:
Update to PAAS’ Onsite Credentialing Guidelines
PAAS National® has created an Onsite Credentialing Guidelines, an extensive checklist to assist PAAS members with scheduled and/or unexpected visits from PBM auditors. Unannounced visits can catch pharmacy staff off guard when the Pharmacist-in-Charge (PIC) is not present. Be sure you are reviewing and advising your staff on the information included on this checklist so they are prepared.
There was an 11% increase in reported onsite audits over the past two years. PAAS takes pride in staying up to date on ever changing trends in pharmacy. Keeping our members informed on PBM inquiries during the credentialing process, or an onsite visit, is one of our priorities. We recently added the following updates to our Onsite Credentialing Guidelines:
Interested in having a customized FWA/HIPAA Compliance program? Contact PAAS to get started today! info@paasnational.com or 608-873-1342.
Audit Risk: Pre-Printed Prescription Forms
At a time when the workday seems to be growing ever more hectic, prescribers and pharmacies may find pre-printed prescription forms convenient; especially for medications which are frequently utilized by a prescriber for treatment. Many PBMs prohibit pre-printed prescription form use for various reasons. Forms created by the pharmacy for the prescriber are concerning because it could appear the pharmacy is soliciting prescriptions or attempting to steer the patient to their pharmacy, particularly if the pharmacy’s name and branding (logo) are pre-printed on the form. Concerns that the forms are not specific enough for each individual patient need with the same quantity, refill number, and directions can also come up.
PAAS National® has seen pre-printed prescription forms considered invalid when they have cascading or overly broad substitutions. For example, if a topical medication is not covered, the form states the prescriber allows the pharmacy to substitute the next topical medication on the form and so on until one is covered. These medications tend to be more expensive than an alternative the plan may prefer and are a red flag for audit when the pharmacy is seen transmitting claims, reversing them, and billing a different product in rapid succession. Many PBM provider manuals have now added language requiring pharmacies to have a verbal conversation with the prescriber before making any substitutions, which would need to be proven with a clinical note documented on the prescription.
PAAS Tips:
Why Does Billing the Correct Origin Code Matter?
Pharmacies are required to enter an origin code on claims to indicate where the prescription came from or “originated.” By definition, an origin code cannot change and should remain billed as how the pharmacy originally received the prescription from the prescriber, even when clarifications of that prescription are done by telephone.
Why does billing the correct origin code matter?
NCPDP defines origin code values as follows:
Here are questions PAAS National® has frequently answered:
Question 1: If a pharmacy calls a prescriber to clarify a written prescription, or a change is needed, does the origin code become a “2” for Telephone?
Answer: No, the NCPDP Telecommunication FAQ section 3.1.5.3 states, “Because the prescription was received via written form the Prescription Origin Code is 1 and will remain a 1 throughout the life of the prescription number.” The same would be true if received by any other origin.
Question 2: If a prescriber sends a prescription electronically, but the pharmacy is not electronically-prescribing enabled or if there is a transmission error, and the intermediary drops the prescription to a fax, what origin code is used?
Answer: Per NCPDP, “Because the prescription was received at the pharmacy via fax the Prescription Origin Code is 4 and will remain a 4 throughout the life of the prescription number.”
Question 3: What origin code is used for a standard written authorization or protocol for services and products like, vaccines or Narcan®?
Answer: The NCPDP definition for protocols is Prescription Origin Code of “5” since the prescription is created by the pharmacy in these cases.
PAAS Tips:
Medicare Caps Copay for Insulin at $35 per Month
As most of you (and your Medicare patients) have undoubtedly noticed, Medicare has applied a $35 per month cap on copays for insulin prescriptions ($105 for a 3-month supply) for years 2023-2025. For 2026 and beyond, copays will be capped at the lesser of $35 or 25% of the negotiated price.
Section 11406 of the Inflation Reduction Act of 2022 implemented this cap for Medicare Part D and Medicare Advantage patients effective January 1, 2023, while Section 11407 requires implementation for Medicare B covered insulin as of July 1, 2023.
Plan Sponsors have a 90-day grace period to implement these copay caps and any excess copays calculated at adjudication must be refunded by the plan.
PAAS Tips:Join today!
- The definition of “one month” varies by plans
- Pharmacies should collect the full copay amount as per online adjudication and advise patients that the plan will refund patients for any amounts in excess of $35 per month
- Pharmacies should be extra diligent when calculating days’ supply and make sure you have mathematical instructions that support the days’ supply adjudicated
- See the Insulin Medication chart and Can You Bill It As 30 Days? tool on the PAAS Member Portal for additional guidance
- The CMS has created the following resources for Medicare patients
- 7 Things to Know about Medicare Insulin Costs
- Frequently Asked Questions About Medicare Insulin Cost-Sharing Changes in the Prescription Drug Law