HME Compliance Documentation

The HME Compliance Documentation Module is available for customers who wish to adjudicate claims to Change Healthcare, but would also like the option to utilize functionality to increase Medicare documentation compliance and to have in the event of an audit. Pharmacies can release a prescription for billing after the proper patient signatures and prescriber documentation are obtained. Documentation includes Proof of Delivery, Medicare Supplier Standards, Assignment of Benefits, Medical Release Authorization, Mobility Assistive Equipment (MAE) Forms and Physicians Orders. This feature is optional and billed on a per claim charge through PowerLine.

READ ME FIRST

After you enroll and complete the set up for the HME Documentation Module, prescriptions for Bin 004766 (Change Healthcare) are transmitted for eligibility and applicable co-pay amounts at the time of filling. However, the prescriptions are not submitted to the insurance company for payment until all required documents are received from the prescriber and patient signatures are acquired. When documentation, dates and signatures are processed into the system, QS/1 Data Collection then transfers all Rxs received on the current day to Change Healthcare. If the prescriptions are accepted, they are then billed to Medicare. Prescription Processing (below) lists the steps to follow to ensure you are reimbursed for your claims.  

Enrollment

Enrollment

Enroll online at www.qs1.com, Service Documents, Medicare Part B Compliance Documentation. Submit the completed enrollment forms to RedSail Pharmacy Services via fax at 864.253.8690 or email to [email protected]. If you have questions regarding enrollment, contact RedSail Pharmacy Services at 800.845.7558, options 7, then 4, then 5.

Set Up Requirements:

After completing enrollment, follow the steps below to use the module:

1. Store must be authorized for the HME Documentation Module.

2. Software system must be NRx or PrimeCare GUI.

3. Task P8DCOLCT must be listed on the server.

4. Task Q8DCJOB1 must be listed on the server.

5. Enhanced Printing must be active.

6. Select printer to use for HME documentation in the Default Printer Selection.

7. The NPI must be entered in Store Control, Store Identification.

8. Click here and follow all steps to set up the Price Plan.

   The Price Plan must contain the following:

   1. ANSI Bin# - 004766 (ERx/Allwin)

   2. Processor Control Number Options:

   • USMCA = Claims process according to which option was selected upon initially enrolling with Emdeon Medicare:

   1. Assigned claims unless affected by Deductible Tracking Service.

   2. Unassigned claims unless dually eligible Medicaid payment, patient has supplement insurance or drug is billed.

   • USMCAASG = Claims process as assigned and any reimbursement is sent to pharmacy.

   • USMCANON = Claims process as unassigned and any reimbursement is sent to the patient.

   • USNONCOVER = This PCN disables all policy edits. Used when a denial is necessary.

   3. Turn on Delayed Label.

   4. Drug Option:

   • 2 for NDC (used by most pharmacies for diabetic and Part B billing).

   • 5 for NDC and State Code (used when NDC and Procedure Code are required for billing).

   • 6 for State Code and Procedure Code (used when the item does not have an NDC number).

   5. Turn on Send Patient Address.

   6. Turn on Send Patient City.

   7. Turn on Send Patient State.

   8. Turn on Send Patient Zip.

   9. Turn on Send Diagnosis.

9. Click here and follow all steps to set up the Drug Record.

   The Drug Record must contain the following:

   1. Drug Record/General Information:

   • Complete the State Code field and select 09 - HCPCS Code as the qualifier if needed.

   • Complete the Procedures Code with modifiers if necessary. Note: Change Healthcare adds modifiers if not included.

   2. Drug Record/Additional Information:

   • Select the Physician Order Code from the drop-down list (this must be done prior to filling the prescription or the Physician Order will not Print.

   • Update the HME Documentation section with the brand and model if needed.

    

10. Click here and follow all steps to set up the Patient Record/Insurance Record for the Price Plan.

    The Patient Record/Insurance Record for the Price Plan must contain the following:

    • Policy Number

    • Person Code

    • Relationship to Cardholder

    • Group MEDIGAP if patient has secondary insurance. This returns a zero co-pay.

     

11. Tickler or Workflow is used for printing HME Documentation.

Prescription Processing

1. Rx is filled for Change Healthcare/Allwin Bin# 004766 and the PCN is USMCA, USMCAASG, USMCANON or USNONCOVER.

2. Paid Response is received in ECS Scan.

3. Rx is held (Release File) by Change Healthcare until it is received through QS/1 Data Collection.

4. The Rx label prints and the Rx is marked as HME Documentation Required.

5. The Rx is moved to one of the following areas: a) Tickler Scan if Workflow is not used, b) Label/Dispense Workflow if Auto Print Labels is turned off or c) Workflow Error Resolution if Label/Dispense is off or Label/Dispense is on and Auto Print Labels is on.

6. Report Options: a) TK-Documents Required = YES or b) WF-Documents Required = YES.

7. If the Label/Dispense queue is used and Auto Print Labels is turned off, the label and HME Documentation print at the same time when Process is selected from the Label/Dispense queue.

8. If printing from Error Resolution or Tickler, the HME Documentation prints separately from the label when Process is selected.

9. Label must print before HME Documentation can be printed.

10. The following documents print depending on the Rx type: a) New Rxs = Proof of Delivery, Supplier Standards, Assignment of Benefits, Medical Release Form, Physician Order Form if selected on Drug Record and MAE prints if the item is used for mobility (cane or walker) or b) Refill Rxs = Proof of Delivery.

11. The Rx is marked as HME Documentation Pending after the documentation prints.

12. After all processes are complete, the Rx is ready for pickup.

13. An electronic signature can be captured at the POS register or Prescription Status in NRx.

14. The signature pad lists the Prescription and HME Documentation they are signing as received.

15. When the signature is accepted for HME Documentation, a prompt displays on the NRx Prescriptions Status or the POS register.

16. The system requires the printed name of the person signing, relationship to the patient and the reason the patient did not sign. This must be completed to satisfy Medicare regulations.

17. On the HME Doc Icon of the RX Transaction, the following occurs: a) the Patient Signature Image updates from the signature pad, b) the printed name, relationship and the reason the patient cannot sign display, c) the Patient Date Signed fields update with the current system date for all HME documents that display on the signature pad at pick-up time, d) the Patient Date Signed fields can be updated manually if signature capture is not available and e) all documents can be reprinted with the signature, date, printed name, relationship and reason patient cannot sign by selecting the appropriate document and clicking Reprint Document(s).

18. The prescriber documentation (Physician Order and/or MAE) must be sent to the physician via mail or fax machine for completion.

19. When returned from the prescriber, the Rx can be accessed from the Workflow Error Resolution queue or Tickler Scan.

20. Report Options: a) TK-Documents Pending = YES or b) WF-Documents Pending = YES.

21. Process the Rx and click the HME Doc icon.

22. Click the Prescriber Documents icon.

23. Enter the date signed and the expiration date of the Physician Order and/or MAE. If the Lifetime field is appropriate, select it instead of entering the expiration date. Click Save.

24. The prescription is sent to data collection and captured at QS/1.

25. Click System Utilities and Scan Data Collection. Functions are: a) Queued is waiting to be sent (usually occurs within 10 minutes), b) Captured is received by QS/1 and the data and time received display and c) Failed indicates there is a transmission problem and customer should click the Reset icon to retransmit all failed Rxs.

26. The Proof of Delivery Date Signed transmits as the date of service on the RX since the date of delivery must be used to meet Medicare delivery requirements. However, the  RX Transaction indicates the original fill date.

27. QS/1 Data Collection then transfers all RXs received on the current day to Change Healthcare at 3:00 AM.

28. If the Rx is accepted, it is billed to Medicare the following Sunday. If the Rx is rejected, QS/1 is notified and emails the customer an Exception Report. Click here to view Exception Report Error Messages. Click here to view a sample Exception Report.

    

    Exception Report Error Messages:

    a. Pick Up Date (HME Patient Signature Date) is invalid - QSU will be given to correct this.

    b. Pick Up Date (HME Patient Signature Date) < Svc date (Rx Fill Date) - Proof of Delivery date signed has been entered incorrectly.

    c.  Rx number not found-Reversal of the Rx has occurred after Rx was sent to data collection.

    d.  Rx number is in a [P] status - Rx was previously billed to Medicare/Medicaid and has been paid in an 835 file received from the payer.

    e.  Rx number is in a [S] status – Rx has been billed to Medicare/Medicaid and payment is pending. 

    f.   Rx number is in a [R] status - Rx has been billed to Medicare/Medicaid and is rejected/denied in an 835 file received from the payer.

    g.  Is not Bill Cycle = (not set as release file) - have Database Services confirm release file option is turned on at Change Healthcare.

    h.  Already in DB, not committing - Rx was previously submitted but it was rejected and will now be released for billing.

29. The customer is instructed to call FastClaim Support.

Documentation Dates

When an Rx is refilled, the Prescriber Document dates are copied to the new Rx, along with the Medical Release, Assignment of Benefits and Supplier Standards if populated on the previous fill. The Proof of Delivery date signed is not copied.

When an Rx is discontinued/reassigned, HME Documentation dates do not copy to the new Rx.

Resubmit to Data Collection

Click here and follow the steps to resubmit an Rx that has a captured status in data collection.

Custom Report

A Custom Report, Missing HME Documentation, is available for downloading from the QS/1 Customer Support Web Page. The report lists all Rxs that have a Proof of Delivery Date Signed, but the Physician Order Date Signed is blank. Click here to view Select, Sort and Print Options for the report. Click here to view a sample Missing HME Documentation Report.

Tickler Processing (Workflow is Turned Off)

Click here to view processing via Tickler when Workflow is turned off.

Workflow Processing (Label/Dispensing is Turned Off)

The steps documented here also apply to Workflow Processing (Label/Dispensing is

Turned On with Auto Print Labels On)

Click here to view processing via Workflow when Label/Dispensing is turned off.

NOTE: If automatic batching is on, select one prescription from the batch and the Proof of Delivery prints all prescriptions in the batch marked as HME Documentation in Error Resolution. The Assignment of Benefits and Medical Release prints up to four prescriptions marked as HME Documentation and then breaks to a new page. The Supplier Standards only print once for a batch which follows Medicare guidelines of providing the standards once.

A separate Physician Order prints for each prescription where the drug record indicates a Physician Order Code. The print date of Proof of Delivery, Assignment of Benefits, Medical Release and Physician Order are updated for each prescription. The print date of the Supplier Standards is only updated on the first prescription of the batch.   

Workflow Processing (Label/Dispensing is Turned On with Auto Print Labels Off)

Click here to view processing via Workflow when Label/Dispensing is turned on and Auto Print Labels is turned off.

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