RPMS POS and Rx RPMS POS and Rx Priority PointsPriority Points

AgendaAgenda

Review definition of Rx Priority Review definition of Rx Priority Points and how they impact the Points and how they impact the determination of which insurer is determination of which insurer is transmitted electronically via POStransmitted electronically via POS

Learn how to troubleshoot Learn how to troubleshoot REFERENCES:REFERENCES:

– ftp://ftp.ihs.gov/rpms/POS/ftp://ftp.ihs.gov/rpms/POS/ POS User folder - Rx Priority Points worksheetPOS User folder - Rx Priority Points worksheet POS User folder – POS User Manual – page 35POS User folder – POS User Manual – page 35

DefinitionDefinition

Rx Priority – points assigned (adding Rx Priority – points assigned (adding weight) to insurer. weight) to insurer.

Rx Priority points are added to BASE Rx Priority points are added to BASE POINTS (located in the POS Set-Up POINTS (located in the POS Set-Up Menu). Menu).

POS selects insurance to transmit POS selects insurance to transmit electronically by determining which electronically by determining which insurance has the most points assigned.insurance has the most points assigned.

Points are assigned in various places in Points are assigned in various places in the POS packagethe POS package

POS selection of POS selection of InsuranceInsurance

Not affected by Patient Registration Not affected by Patient Registration package sequencingpackage sequencing

Selection criteria:Selection criteria:– Base pointsBase points– Rules among private insurersRules among private insurers– Points for particular insurers (POS / MGR / Points for particular insurers (POS / MGR /

SET / INS / ADV)SET / INS / ADV)– Insurer added most recently to patient Insurer added most recently to patient

registration recordregistration record

Base PointsBase Points

Enter the base scores for each insurance type.Enter the base scores for each insurance type.

For example, if Private insurance is usually primary, and For example, if Private insurance is usually primary, and Medicaid is secondary and Medicare is tertiary then Medicaid is secondary and Medicare is tertiary then you might give Private 900 points, Medicaid 600 you might give Private 900 points, Medicaid 600 points, Medicare and Railroad each 300 points and points, Medicare and Railroad each 300 points and Self pay 100 points.Self pay 100 points.

INS BASE PRVT: 900//INS BASE PRVT: 900//INS BASE CAID: 600//INS BASE CAID: 600//INS BASE CARE: 300//INS BASE CARE: 300//INS BASE RR: 300//INS BASE RR: 300//INS BASE SELF: 100//INS BASE SELF: 100//

Additional Insurance Additional Insurance RulesRules

Birthday rule (2 parents)Birthday rule (2 parents) Policy Holder is SelfPolicy Holder is Self Workers Comp RuleWorkers Comp Rule

Insurer PointsInsurer Points

Extra points for specific insurersExtra points for specific insurers POS / MGR / SET / INS / ADVPOS / MGR / SET / INS / ADV Rx Priority PointsRx Priority Points

– Insurer name used for Medical and Insurer name used for Medical and Pharmacy Claims – 5 pointsPharmacy Claims – 5 points

– Insurer name used only for Pharmacy Insurer name used only for Pharmacy claims – 20 pointsclaims – 20 points

– Medicare Part D insurer - >600 points; Medicare Part D insurer - >600 points; recommend 650 points if Medicare Part D recommend 650 points if Medicare Part D is primaryis primary

SEE Rx Priority SEE Rx Priority WorksheetWorksheet

Calculate PointsCalculate Points

Assume base points have not been Assume base points have not been adjusted. However, it would be good to adjusted. However, it would be good to verify.verify.

INS BASE PRVT: 900//INS BASE PRVT: 900// INS BASE CAID: 600//INS BASE CAID: 600// INS BASE CARE: 300//INS BASE CARE: 300// INS BASE RR: 300//INS BASE RR: 300// INS BASE SELF: 100//INS BASE SELF: 100//

Calculate PointsCalculate Points

Select INS RULE ORDER: 20//Select INS RULE ORDER: 20// INS RULE ORDER: 20//INS RULE ORDER: 20// INS RULE NAME: POLICY HOLDER INS RULE NAME: POLICY HOLDER

IS SELF//IS SELF// INS RULE POINTS PLUS: INS RULE POINTS PLUS: 10//10// INS RULE POINTS MINUS: INS RULE POINTS MINUS:

Calculate PointsCalculate Points

----- Using electronic FORMAT: MEDICARE PARTD RXSOLUTIONS 5.1----- Using electronic FORMAT: MEDICARE PARTD RXSOLUTIONS 5.1 BIN: 610097BIN: 610097D-PACIFICARE SAVER STANDARD 650.00D-PACIFICARE SAVER STANDARD 650.00 ----- Using electronic FORMAT: NATIONAL PHARM SVCS 5.1----- Using electronic FORMAT: NATIONAL PHARM SVCS 5.1 BIN: 004758BIN: 004758NATIONAL PHARMACEUTICAL SER STANDARDNATIONAL PHARMACEUTICAL SER STANDARD ----- Using electronic FORMAT: PAID 5.1----- Using electronic FORMAT: PAID 5.1 BIN: 610014BIN: 610014GOVERNMENT EMPLOYEES HOSP ASSN STANDARD GOVERNMENT EMPLOYEES HOSP ASSN STANDARD

5.005.00MERCK-MEDCO RX SERVICES STANDARD MERCK-MEDCO RX SERVICES STANDARD

20.0020.00MEDCOHEALTH STANDARD 20.00MEDCOHEALTH STANDARD 20.00