Pharmacy Provider Manual - express-scripts.ca

1 Pharmacy Provider Manual Claims Submission for Participating Pharmacies Applicable to all provinces and territories (excluding Quebec and Newfoundland and Labrador). June 2016. Optimizing the Version Value of Health Benefits Page 1 of 46 January 2012. Version: Any comments or requests for information may be transmitted to: Express Scripts Canada Attention: Provider Relations 5770 Hurontario Street, 10th Floor Mississauga, ON L5R 3G5. The information contained in this document is subject to change without notice. The data used in the examples are fictitious, unless otherwise noted. In case of discrepancies between the English and French version, the English version will prevail. 2009-2016 Express Scripts Canada.

2 All Rights Reserved. Express Scripts Canada (ESC) is a registered business name of ESI Canada, an Ontario partnership. All reproduction, adaptation or translation is prohibited without prior written authorization, except for the cases stipulated by the Copyright Act. The registered or non-registered trademarks and the registered product names belong to their respective owners. The Pharmacy Provider Manual is subject to the terms and conditions of the Express Scripts Canada Pharmacy Provider Agreement1. 1 The Express Scripts Canada Pharmacy Provider Agreement is the agreement governing the electronic adjudication by Express Scripts Canada of claims submitted by the Pharmacy on behalf of a patient and entered into between Express Scripts Canada and the Pharmacy , whether directly or through an association which the Pharmacy is a member of and to which the Pharmacy has assigned the authority to enter into such agreement on its behalf.

3 Pharmacy Provider Manual Table of Contents 1. Defined 5. 2. Introduction .. 7. Overview .. 7. Role of Express Scripts 7. Express Scripts Canada Clients .. 8. Claim Transmission Relationship .. 9. General Terms .. 9. Express Scripts Canada Pharmacy Provider Manual - Purpose .. 10. 3. Adjudication System Overview .. 10. Real-Time Processing System .. 10. Adjudication System 10. 4. Express Scripts Canada Pharmacy Provider Agreement .. 11. Unique Provider 11. Change in Ownership/ Provider Information .. 11. Supremacy .. 11. Usual and Customary Professional Fee .. 12. Liability 12. Pharmacy Reimbursement .. 13. 5. Manual Claims Submission .. 14. Mandatory Information for Claims over $9.

4 14. 6. Electronic Claims Submission .. 15. Mandatory Information in Transmissions .. 15. Transmission Delays .. 15. Claim Reversal .. 15. Transmission of Claims for Compounds .. 16. Drug Utilization Review .. 16. Prescriber Identification 18. Actual Day's Supply .. 18. Dispensing Quantity .. 18. Co-ordination of Benefits .. 19. 7. Drug Benefit Plan Limitations .. 20. General Limitations .. 20. Prior Authorization .. 22. 8. Audits .. 23. Audit Program .. 23. Audit 24. Provider Responsibility .. 26. 9. Pricing .. 26. Same Level Playing Field .. 26. 10. New Programs .. 27. Step Therapy 27. Provincial Integration Program .. 29. 11. Contact 32. Express Scripts Canada Website .. 32. Provider Call Centre.

5 32. Canadian Pharmacists Association .. 33. Software Certification/Network Communications .. 33. 12. Appendices .. 33. Appendix A Sample Modification to Pharmacy Provider Information 34. Appendix B Response Codes/Explanations .. 35. Appendix C Sample Pharmacy Provider Remittance 45. Appendix D Product Selection Code List .. 46. June 2016 Page 3 of 46. Version: Pharmacy Provider Manual Document Revision and History Version Revision Date Details December 2010 Revision November 2012 Revision April 2016 Revision Page 4 of 46 June 2016. Version: Pharmacy Provider Manual 1. Defined Terms The defined terms below lists the terms and definitions, which are relevant for background information when reading the Pharmacy Provider Manual .

6 Term Definitions Appendices Each Appendix A, B, C and D attached hereto and incorporated herein by this reference are substantially representative of the forms detailed throughout this Manual , each of which may be updated or modified, by Express Scripts Canada, at its sole discretion, without the necessity of revising the representative form as attached hereto. Benefits The individual responsible for administering the drug benefit plan Administrator details with the client on behalf of the drug benefit plan members. Carrier The insurance company, insurer and insurance carrier. Refer to client below. Claim A claim for which the Pharmacy Provider or member applies for reimbursement for a portion of the cost of a dispensed covered medication.

7 Client The insurance carrier, third party administrator (TPA),employer or other organization having principal financial responsibility for payment of covered medications provided to members under a drug benefit plan. Co-ordination of Co-ordination of benefits between two drug benefit plans, whether Benefits (COB) they are either private, or a mix of public and private coverage. Copayment That portion of the total charge for each covered medication that a member is required to pay to the Pharmacy Provider or to the pharmacies in accordance with that member's drug benefit plan, whether designated as a copayment or deductible. Covered Those prescription drugs, supplies and other items prescribed by an Medication authorized, licensed practitioner that are covered by a drug benefit plan.

8 CPhA Canadian Pharmacists Association CPhA Pharmacy The standard rules of electronic claims transmission published by Claim Standard the CPhA. A copy may be obtained directly from the following address: Canadian Pharmacists Association 1785 Alta Vista Drive Ottawa, ON K1G 3Y6. Phone: 613-523-7877. Fax: 613-523-0445. Deferred Claim An electronically submitted claim for which the member pays the Pharmacy Provider for the entire cost of the covered medications upon dispensing, and later receives reimbursement by the client for the portion of the cost taken on by the latter. June 2016 Page 5 of 46. Version: Pharmacy Provider Manual Term Definitions Direct Claim An electronically submitted claim for which the payment of the portion of the cost of the covered medication taken on by the client is made to the Pharmacy Provider directly by the client.

9 Drug Benefit A healthcare plan pursuant to which prescription drug benefits are Plan or Plan available to members. Formulary A list of covered medications prepared by Express Scripts Canada for a client and revised periodically and includes, without limitation, drugs. Physicians are encouraged to prescribe and pharmacists to dispense, consistent with their professional judgment and applicable medical and pharmaceutical laws and procedures, which members are encouraged to use. Identification The printed identification information card issued to member Card pursuant to the applicable drug benefit plan bearing the Express Scripts Canada logo and the third party payer's logo. Member A subscriber, their spouse and eligible dependents to which benefits are available pursuant to a drug benefit plan.

10 Ontario Drug Drug plan program for the province of Ontario. Benefit (ODB). Pharmacy A Pharmacy Provider (also referred to as the Provider ) is bound by Provider the terms and conditions set forth in the Express Scripts Canada Pharmacy Provider Agreement; also referred to as the participating Pharmacy . Pharmacy Written description of procedures that Pharmacy providers are Provider Manual required to follow when dispensing covered medications to or Manual members in order to receive reimbursement for each claim (developed by Express Scripts Canada). Pharmacy A type of software used by a Pharmacy Provider to capture all Practice relevant data when dispensing medication in accordance with a Management prescription and the CPhA Pharmacy claim standard.