============================================================================= Run Date: OCT 20, 2004 Designation: IB*2*223 Package : IB - INTEGRATED BILLING Priority: Mandatory Version : 2 SEQ #260 Status: Released Compliance Date: NOV 20, 2004 ============================================================================= Associated patches: (v)IB*2*13 <<= must be installed BEFORE `IB*2*223' (v)IB*2*115 <<= must be installed BEFORE `IB*2*223' (v)IB*2*137 <<= must be installed BEFORE `IB*2*223' (v)IB*2*183 <<= must be installed BEFORE `IB*2*223' (v)IB*2*202 <<= must be installed BEFORE `IB*2*223' (v)IB*2*245 <<= must be installed BEFORE `IB*2*223' (v)IB*2*247 <<= must be installed BEFORE `IB*2*223' Subject: SUPPORT FOR NCPDP BILLING Category: - Data Dictionary - Routine - Informational Description: ============ PATCH OVERVIEW --------------- The Healthcare Insurance Portability and Accountability Act National Council for Prescription Drug Programs (HIPAA NCPDP) initiative, whose ultimate goal is to provide functionality allowing electronic transmission of Outpatient Pharmacy (OP) prescription claims to payers and the receipt of claim responses (including drug utilization review responses and warnings) on a real-time basis, is being developed and introduced in a phased implementation strategy. This deployment strategy was utilized due to the complexity of the functionality and the number of product line dependencies. The first release of this two part implementation is BPS*1.0, comprised of the new Electronic Claims Management Engine (ECME) package (in the BPS namespace), plus the patches PSS*1*81, IB*2.0*223, IB*2.0*251, and PRCA*4.5*202, which are listed here in order of installation.The patches are combined in host file BPS_1_0.KID in order to simplify installation. BPS*1.0 is a dormant release that only allows each site to perform preliminary setup work and to confirm that the software does not adversely affect other packages. There are two main areas addressed by BPS*1.0: a. Registration of the Pharmacy with the Vitria BusinessWare IE. b. The Insurance Matching of Group Plans with Pharmacy Plans Following the installation of BPS*1.0, each site must register their pharmacy with Vitria and match applicable insurance group plans using the insurance matching screens. These processes are detailed in the HIPAA NCPDP CONNECTION FOR EDI PHARMACY (Dormant Release) INSTALLATION GUIDE and the E-PHARMACY CLAIMS INSURANCE PROCESS document. Both of these documents are located on the anonymous directory. It is very important that the IRM or person installing the patch at each facility provide a copy of these documents to its ADPAC(s) and any other relevant staff who will be responsible for registering their pharmacy with Vitria and completing the insurance matching process. At a later date, additional HIPAA NCPDP patches will be released to activate all of the HIPAA NCPDP functionality. Until that time, sites will not be able to electronically submit claims utilizing this new functionality. The HIPAA NCPDP project was created in response to a Chief Business Office (CBO) request for modifications to several Veterans Health Information Systems and Technology Architecture (VistA) software applications in accordance with HIPAA Electronic Data Interchange (EDI) transactions and NCPDP mandated format standards, specifically the NCPDP Telecommunication Standard v.5.1. The specific functionality for this patch is listed below. Functional Description ---------------------- This patch adds the necessary enhancements to the Integrated Billing package to support NCPDP (National Council for Prescription Drug Programs) billing of pharmacy claims via the Outpatient Pharmacy package. The features are: 1. When a patient is issued medication via Outpatient Pharmacy, Outpatient Pharmacy will check with Integrated Billing (IB) to determine if the prescription is NCPDP billable to a third party payer. The patient must have active, reimbursable insurance that covers prescriptions as specified in the patient's group policy coverage limitations. The prescription must not be for OTC or research medications and must not be related to SC (Service Connected), AO (Agent Orange), IR (Ionizing Radiation), EC (Environmental Contaminants), HNC (Head/Neck Cancer), CV (Combat Veteran), or MST (Military Sexual Trauma). 2. A check will be done to see if the site's Claims Tracking module is turned on for prescriptions. When it is, the appropriate information will be entered into that module in IB. To ensure that the Autobiller does not bill the prescription on a paper claim until the electronic transmission can be processed, the EARLIEST AUTOBILL DATE will be set for 60 days into the future. If the claim is not processed or resolved in pharmacy within 60 days, then a paper claim will be automatically generated. 3. If the bill for the prescription is approved by the third party insurance carrier for payment, Outpatient Pharmacy will make a second call to IB. At that time, IB will create a bill in the BILL/CLAIMS (#399) file for the amount of the total charge. The bill will be automatically authorized and passed to Accounts Receivable (AR). IB will have AR automatically audit the receivable and post a decrease adjustment so that the amount of the outstanding receivable will be equal to the amount of payment expected from the payer. 4. If a prescription bill is rejected, Outpatient Pharmacy will make a second call to IB. Assuming Claims Tracking is active for prescriptions, IB will check to make sure the prescription is in Claims Tracking. The Claims Tracking entry will be picked up by the Autobiller to ensure proper follow-up is done. 5. If a prescription bill is reversed in Outpatient Pharmacy, both the bill and receivable will be cancelled. 6. To support claims other than Reimbursable Insurance for Veterans, IB will ask for both the Administrative Fee and Dispensing Fee when a rate schedule adjustment is entered. These are optional and will be sent in the NCPDP transmission. 7. To assist with the posting of payments, the API used to look up bills to post payments in the Accounts Receivable package has been updated to allow for input of the ECME number. Technical Description --------------------- IB20P223 is an environment check to ensure that the site has 4 national rate types defined. If the rate types are not defined, a site will need to defined them prior to install. The 4 rate types are: CHAMPUS (or TRICARE) CHAMPUS REIMB. INS. (or TRICARE REIMB. INS.) CHAMPVA CHAMPVA REIMB. INS. If your site does not have the exact spelling as shown above, you should contact EVS for assistance. Your site may have them defined but the names may have been changed. This routine also has a post install that will add two reasons not billable. They are: HEAD/NECK CANCER COMBAT VETERAN IBCRCC has an optional parameter in the RATECHG line tag of FEE. If this parameter is passed by reference, the API will return any Administrative Fee and Dispensing Fee amounts for the Rate Schedule. IBCREE has been modified to capture the Administrative Fee and Dispensing Fee, if appropriate. The Rate Schedule adjustment must have an amount added in the calculation of the adjustment for the fee questions to be asked. IBCRU3 has been modified to add a new entry point to look up the event pointer based on a rate type. IBJTCA1 is included to add enhancements to the Third Party Joint Inquiry to display new information that relates to ECME claims. IBNCPDP is the main API routine to be used by Outpatient Pharmacy. All new APIs will be supported with this routine. IBNCPDP1 will handle the initial call by Outpatient Pharmacy. This routine will load the prescription information to Claims Tracking, look up insurance information, verify active pharmacy coverage and return the necessary billing information so that a NCPDP claim can be produced. IBNCPDP2 will handle all response information sent from Outpatient Pharmacy. This routine will create bills, authorize bills, audit bills, adjust bills, cancel bills and ensure that the claims are updated in Claims Tracking. IBNCPDP3 will handle Average Wholesale Pricing updates. IBNCPCPU will be a utility routine for all the NCPDP billing needs in IB. IBRFN has been updated to allow for input of an ECME number when posting payments in the Accounts Receivable package. The API for AR will now return the type of lookup found. IBRUTL is being included to suppress the third party billing bulletin when a first party bill goes on hold for third party billing and the bill has already been billed using the ECME software. IBTUTL1 has been modified to accept an additional optional parameter in the REFILL line tag for the EARLIEST AUTOBILL DATE. If the new parameter is specified in the call, that date will be used instead of the existing functionality. COMPONENTS SENT WITH PATCH -------------------------- The following is a list of the routine(s) included in this patch. The second line of each of these routine(s) will look like: ;;2.0;INTEGRATED BILLING;**[patch list]**;21-MAR-94 CHECK^XTSUMBLD results Routine Before Patch After Patch Patch List ------- ------------ ----------- ---------- * IB20P223 N/A 2185163 223 IBCRCC 7424137 7476482 52,80,106,138,245,223 IBCREE 20456836 21593159 52,106,115,223 IBCRU3 5450420 6652039 52,106,223 IBJTCA1 16164807 16640403 39,80,106,137,223 IBNCPDP N/A 355298 223 IBNCPDP1 N/A 13353250 223 IBNCPDP2 N/A 16386559 223 IBNCPDP3 N/A 758252 223 IBNCPDPU N/A 8111193 223 IBRFN 4021093 6787815 52,130,183,223 IBRUTL 3925983 4993649 70,82,132,142,176,179,202,223 IBTUTL1 5460777 6092014 13,223 Total number of routines - 13 * NOTE: THIS ROUTINE WILL BE AUTOMATICALLY DELETED AFTER INSTALL. Data Dictionary Changes: UP SEND DATA USER DATE SEC. COMES SITE RSLV OVER FILE # NAME DD CODE W/FILE DATA PTS RIDE ------------------------------------------------------------------------------ 361.1 EXPLANATION OF BENEFITS YES NO NO NO Partial DD: subDD: 361.1 fld: .14 DATA SCREEN: 363 RATE SCHEDULE YES NO NO NO Partial DD: subDD: 363 fld: 1.01 fld: 1.02 DATA SCREEN: 399 BILL/CLAIMS YES NO NO NO Partial DD: subDD: 399 fld: 460 fld: 461 DATA SCREEN: Test Sites: =========== NEW YORK HARBOR HCS NORTH TEXAS HCS ANN ARBOR, MI BATTLE CREEK, MI DETROIT, MI IRON MOUNTAIN, MI SOFTWARE AND DOCUMENTATION RETRIEVAL ==================================== The software for this patch is being distributed in host file BPS_1_0.KID. The host file will contain four patches and one package release. The builds contained in the BPS 1.0 multi-package distribution are: Package Patches/Package ------- ---------------------- ECME BPS*1.0 Pharmacy Data Management PSS*1.0*81 Integrated Billing IB*2.0*223, IB*2.0*251 Accounts Receivable PRCA*4.5*202 Please refer to the 'Software and Documentation Retrieval' section of the BPS*1.0 build description for instructions on how to acquire the patch software and documentation. INSTALLATION INSTRUCTIONS ========================== 1. Use VA FileMan to add the new domain, EPHARMACY.VITRIA-EDI.AAC.VA.GOV, to the DOMAIN file (#4.2). The installation instructions are included in the patch description for the XM*DBA*160 patch. This domain must be in place before the installation of the IB*2*251 patch that is included in the BPS 1.0 Master Build. 2. Download the KIDS file BPS_1_0.KID via FTP. This file needs to be retrieved in ASCII format. 3. Review mapped sets for the PSS*, IB*, and PRCA*namespaces. If the routines are mapped, they should be removed from the mapped set at this time. 4. From the Kernel Installation & Distribution System menu, select the Installation menu. 5. From this menu, select the Load a Distribution option. When prompted for a file name, enter the directory name where you FTPd the build, followed by BPS_1_0. In our example, the file name is USER$:[ANONYMOUS]BPS_1_0.KID. Determine the location where you stored your build to decide the correct file name entry. 6. At the "Want to Continue with Load? YES//" prompt, enter YES. 7. At the "Want to RUN the Environment Check Routine: YES//" prompt, answer YES. 8. From this menu, the installer may select to use the following options: (When prompted for INSTALL NAME, enter BPS 1.0) a. Backup a Transport Global - This option will create a backup message of any routines exported with the patch. It will NOT backup any other changes such as DDs or templates. b. Compare Transport Global to Current System - This option will allow you to view all changes that will be made when the patch is installed. It compares all components of the patch (routines, DDs, templates, etc.). c. Verify Checksums in Transport Global - This option will ensure the integrity of the routines that are in the transport global. 9. At the "Select Installation Option:" prompt, enter 6 Install Package(s) 10. At the "Select INSTALL NAME:" prompt, enter BPS 1.0. 11. When prompted, "Want KIDS to Rebuild Menu Trees Upon Completion of Install? YES//" respond NO. 12. When prompted, "Want KIDS to INHIBIT LOGONs during the install? YES//" respond NO. 13. When prompted, "Want to DISABLE Scheduled Options, Menu Options, and Protocols? YES//" respond NO. 14. When prompted, "Device:Home//" respond with the correct device and DO NOT queue this to P-Message. 15. If routines were unmapped as part of step 3, they should be returned to the mapped set once the installation has run to completion. Routine Information: ==================== Routine Name: - IB20P223 Routine Checksum: Routine Name: - IBCRCC Routine Checksum: Routine Name: - IBCREE Routine Checksum: Routine Name: - IBNCPDP Routine Checksum: Routine Name: - IBNCPDP1 Routine Checksum: Routine Name: - IBNCPDP2 Routine Checksum: Routine Name: - IBNCPDP3 Routine Checksum: Routine Name: - IBNCPDPU Routine Checksum: Routine Name: - IBTUTL1 Routine Checksum: Routine Name: - IBCRU3 Routine Checksum: Routine Name: - IBJTCA1 Routine Checksum: Routine Name: - IBRFN Routine Checksum: Routine Name: - IBRUTL Routine Checksum: ============================================================================= User Information: Entered By : ZEIGLER,EDWARD L Date Entered : JUN 17, 2003 Completed By: TORRANCE,LORI Date Completed: OCT 18, 2004 Released By : BOTTINI,STEVE Date Released : OCT 20, 2004 ============================================================================= Packman Mail Message: ===================== No routines included