RA Messages from June 27, 2000

PHARMACY PROVIDERS, PLEASE NOTE!!!

IF YOU ARE UNSURE ABOUT THE COVERAGE OF A DRUG PRODUCT, PLEASE CONTACT THE PBM HELP DESK AT 1-800-648-0790                                   

PLEASE MAKE THE FOLLOWING CHANGES TO THE 5/15/00 VERSION OF APPENDIX A:  

PLEASE FILE ADJUSTMENTS FOR CLAIMS WHICH MAY HAVE BEEN INCORRECTLY PAID.

PHARMACY PROVIDERS:

EFFECTIVE 6/18/00, THE PROSPECTIVE DRUG UTILIZATION CLINICAL EDITS WILL NOW BE CREATED BY A NEW PROGRAM, UNIDUR. THE UNIDUR PROGRAM WILL GENERATE ALERT MESSAGES AS THE PRODUR PROGRAM. PHARMACISTS WILL RECEIVE A  UNIDUR PHARMACY PROVIDER HANDBOOK WHICH DETAILS THE UNIDUR MODULES. THE PBM HELP DESK (800-648-0790) WILL BE AVAILABLE TO RESPOND TO ANY QUESTIONS.

NOTICE TO HOSPITALS

WE HAVE RECENTLY RECEIVED A REQUEST FOR CLARIFICATION OF BILLING PROCEDURES AND REIMBURSEMENT FOR OUTPATIENT HOSPITAL SURGICAL PROCEDURES.

 OUTPATIENT HOSPITAL CLAIMS THAT INCLUDE ANY ICD-9 PROCEDURE WHOSE FIRST TWO DIGITS ARE IN THE RANGE OF "01" THROUGH "86," ARE TO BE BILLED INCLUDING REVENUE CODE 490 (HR 490) FOR THAT PROCEDURE.

IN KEEPING WITH OUR PREVIOUS MEMO TO HOSPITAL PROVIDERS DATED JULY 30, 1999, REGARDING OUTPATIENT CODING FOR PPS DATA COLLECTION, WE ARE REQUESTING THAT ALL CPT OR HCPCS CODES BE INCLUDED ON THE CLAIM FOR ALL ITEMS TYPICALLY REQUIRING A CPT OR HCPCS CODE FOR MEDICARE.

THE OUTPATIENT SURGICAL PROCEDURES THAT ARE INCLUDED IN ONE OF THE FOUR ALREADY ESTABLISHED SURGICAL GROUPINGS WILL BE REIMBURSED THE FLAT FEE  FOR THAT PARTICULAR GROUPING. THE FLAT FEE REIMBURSEMENT WILL BE REFLECTED AS PAYMENT FOR THE HR 490 CODE AND THE REMAINING CLAIM LINES WILL BE REFLECTED AS DENIED. 

FOR THE OUTPATIENT SURGICAL PROCEDURES THAT ARE NOT INCLUDED IN ONE OF THE FOUR ALREADY ESTABLISHED SURGICAL GROUPINGS, REIMBURSEMENT WILL BE AT 60% OF BILLED CHARGES FOR EACH CLAIM LINE (INCLUDING THE SURGICAL PROCEDURE BILLED WITH REVENUE CODE 490), EXCEPT FOR THE REVENUE CODES THAT ARE PAID AT A FLAT FEE, SUCH AS LABORATORY SERVICES. 

IF FURTHER QUESTIONS ARISE, PLEASE CONTACT PROVIDER RELATIONS AT (800)  473-2783 OR (225) 924-5040.