STATE OF NEW YORK
DEPARTMENT
OF HEALTH
eMedNY
Prospective
Drug Utilization Review/
Electronic
Claims Capture and Adjudication
ProDUR/ECCA
Provider Manual
February 23, 2005
Version 1.14
STATE OF NEW YORK
DEPARTMENT
OF HEALTH
eMedNY
Prospective
Drug Utilization Review/
Electronic
Claims Capture and Adjudication
ProDUR/ECCA
Provider Manual
February 23, 2005
Version 1.14
TABLE OF CONTENTS
Section
2.4 Electronic
Claims Capture and Adjudication (ECCA)
2.5 Medicare
and Third Party Claims
Chart 1 –
Recipient with Coverage Codes H, K, M, O or ALL on file
Chart 2 -
Recipient without Coverage Codes on file
2.6 Rebills/Adjustment
Information
2.8 Health
Care Financing Administration Common Procedure Coding System (HCPCS)
2.10 Dispensing
Validation System
2.11 Prior
Auth Type Code and Prior Auth Number Submitted
2.12 Temporary
Medicaid Authorizations
2.13 Excess
Income/Spenddown Claims
2.14 Duplicate
Claim Transactions
Reason For
Service (Conflict Code)
Other
Pharmacy Indicator (529-FT)
Previous Date
of Fill (530-FU)
Quantity of
Previous Fill (531-FV)
Other
Prescriber Indicator (533-FX)
Conflict Code
Free Text Descriptions
4.2 Utilization
Threshold (UT) Override
5.0 Pro-DUR/ECCA Input Information
6.0 PRO-DUR/ECCA RESPONSE MESSAGES
7.0 PRO-DUR/ECCA REVERSAL/CANCEL
TRANSACTIONS
9.0 MEVS ACCEPTED CODES - TABLE 1
10.0 MEVS DENIAL CODES - TABLE 2
11.0 CO-PAYMENT CODES - TABLE 6
12.0 Rx DENIAL CODES - TABLE 7
13.0 PHARMACY UT/P & C CODES - TABLE 8
14.0 DISPENSING VALIDATION SYSTEM REASON
CODES - TABLE 9
15.0 PEND REASON CODES – TABLE 10
17.0 GLOSSARY OF ABBREVIATIONS AND TERMS
The New York State Department of Health (DOH) has implemented a program that allows the pharmacy community to submit MEVS transactions in an online real-time environment that performs a Prospective Drug Utilization Review (Pro-DUR). This program was implemented on June 1, 1994 and is currently being administered by the eMedNY contractor. In order to receive payment for services rendered, all pharmacies must submit their transactions through the online ProDUR system. An optional feature of the ProDUR program is the Electronic Claim Capture and Adjudication (ECCA) of claims by the eMedNY contractor. The purpose of the Pro-DUR program is to be in compliance with OBRA 90 mandated Pro-DUR requirements. This program will check all prescriptions with prescription drugs the recipient has taken over the past 90 days and alert the pharmacists to possible medical problems associated with dispensing the new drug.
The telecommunication standards for the Pro-DUR/ECCA system are the same as those recommended by the National Council for Prescription Drug Program, Inc. (NCPDP) and named under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Only the NCPDP 5.1 Telecommunications standard and the 1.1 Batch formats are supported. The New York State format specifications were developed by using the Official Release of the NCPDP Version 5 Release 1 standard and the 1.1 Batch standard. The NCPDP Official Release is available to NCPDP members from the following address:
National Council for Prescription Drug Programs Inc.
9240 East Raintree Drive
Scottsdale, AZ 85260
(480) 477-1000
The mandatory Pro-DUR/ECCA program was implemented June 1, 1994 and is currently being administered by the eMedNY contractor. In order to receive payment for services rendered, all pharmacies must submit their transactions through the online Pro-DUR program using the NCPDP transaction format. Each pharmacy must choose an access method for these transactions. It is also each pharmacy's decision as to whether the transactions go directly to the eMedNY contractor or through a switch company, which in turn sends the transactions to the eMedNY contractor for processing.
Each online claim transaction is processed through the eligibility edits first, then through the Utilization Threshold (UT), Post and Clear (P&C), DUR, and Dispensing Validation System processing, if warranted. An accepted transaction gives you all the necessary UT, P&C and DUR authorizations in addition to recipient eligibility information. There is no need to do an eligibility or UT service authorization inquiry on the Verifone Omni 3750 Terminal or via telephone.
If you are already processing your transactions online, you should not be sending the same transaction through the Verifone Omni 3750 Terminal (transaction 1). This causes two service authorizations to be issued and increases the UT counts for the recipient. A recipient could reach his/her UT limit in error if double service authorizations were posted.
The Pro-DUR/ECCA online system is an adjudication system.
The dollar amount returned in the online response is not the amount that you
will be paid. It is the maximum reimbursable unit price amount.
The online system was designed to allow for capture and adjudication of the electronic submission. It is each pharmacy's option as to whether the claim data should be immediately captured online by the eMedNY contractor for payment or if the actual claim will be sent by the provider using paper or electronic batch .
There are four potential access methods for submission of claims through the DUR system:
· PC to host - your Personal Computer will directly dial the MEVS host.
· CPU to CPU - your computer system has a dedicated communication line directly into the MEVS host processor.
· CPU to CPU through a switching company - your Personal Computer will access the MEVS host through a switching company. This access could be through dial up or leased line. The switching company will have a direct line into the MEVS host processor.
· eMedNY eXchange – a web-based application used to submit HIPAA compliant batch transactions to the eMedNY system. This method works in a similar fashion to email, where transaction files are sent as an attachment, and delivered after processing to the users inbox.
Providers must select one of the alternate access methods. If they choose not to use a switching company, they must become certified with the eMedNY contractor to verify their ability to access and process within the MEVS system. Submission via PC-Host or CPU-CPU access (switch or direct) allows up to a maximum of four claims per transaction.
Note: Switching companies or software vendors may restrict claims per transaction to less than four.
Pharmacies selecting the PC-to-Host access method must call 1-800-343-9000 to request a contract and certification package. If choosing to access through a switch, pharmacies must notify the switch and the switch company must notify the eMedNY contractor of the pharmacy’s name and MMIS provider number.
Once a pharmacy has selected an alternate access method, they
will receive communication protocol information from the eMedNY contractor or
from their switching company. For more information on these access methods OR
if you would like a copy of the Pro-DUR/ECCA Standards Manual please contact
the Provider Services Department at
1-800-343-9000.
The card swipe function will still be available on the Verifone Omni 3750 Terminal for pharmacy providers who are designated by NYSDOH Quality Assurance and Audit Office as card swipe providers. Designated pharmacies must swipe the recipient's card on the Verifone Omni 3750 Terminal using transaction type 5, prior to entering the online DUR transaction. No DATA should be entered on the Verifone Omni 3750 Terminal. The eMedNY contractor will match the transactions to ensure that a swipe was performed. Only transaction type 5 will register and match the swipe to the online DUR transaction. The swipe only has to be done once for each recipient per date of service, regardless of the number of prescriptions being filled that day for that particular recipient.
Responses will be returned via the same alternate access method as the input transaction. The response for each claim will either be accepted or rejected. If the claim is rejected, reject codes will be provided to identify the nature of the problem.
If the claim has passed all edits and is acceptable, a C (Captured) will be returned