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Client Version Audit Code to IN Admin Code Approved 061509

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9 pages
INFSSAInformation For Final Determination LettersAudit Where To Look For More What Was Found What Went Wrong How To Fix It Citation of Administrative CodeCode InformationINDIANA HEALTH COVERAGE PROGRAMS PROVIDER MANUAL: Chapter 9: Pharmacy Pharmacy has the option to submit Services:Libraray Reference The prescription was written as a an Indiana Medicaid Compound Number PRPR10004 (Revision TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND Claim should be billed as a compound however, the Drug Claim Form to Prudent Rx. All Date March 2009 Version 8.1)CC SOCIAL SERVICES 405 IAC 1-5-1 Medical records; compound pharmacy did not bill it as a refills should be corrected and contents and retentioncompound. billed with the appropriate The Medicaid Compound Drug compound claim indicator. Claim Form, as well as detailed billing instructions, can also be found on the IHCP Web site at www.indianamedicaid.com.Excluded from recovery per client No further action is required by the CE N/A N/A N/Arequest pharmacy.The pharmacy indicates that there No further action is required by the Claim does not belong to is no record of the prescription CL pharmacy; the claim will be N/A N/Apharmacy and/or patient in their computer recouped.system.No further action is required by the CN Audit cancelled N/A N/A N/Apharmacy.TITLE 21 - FOOD AND DRUGSCHAPTER 13 - DRUG ABUSE TITLE 21 - FOOD AND DRUGSPREVENTION AND CONTROL CHAPTER 13 - DRUG ABUSE PREVENTION AND SUBCHAPTER I ...
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No further action is required by the N/A pharmacy.
What Was Found
Audit Code
Claim was previously reversed by the pharmacy
N/A
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER MANUAL: Chapter 9: Pharmacy Pharmacy has the option to submit Services:Libraray Reference an Indiana Medicaid Compound Number PRPR10004 (Revision TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND Drug Claim Form to Prudent Rx. All Date March 2009 Version 8.1) SOCIAL SERVICES 405 IAC 151 Medical records; refills should be corrected and contents and retention billed with the appropriate The Medicaid Compound Drug compound claim indicator. Claim Form, as well as detailed billing instructions, can also be found on the IHCP Web site at www.indianamedicaid.com.
Citation of Administrative Code
How To Fix It
N/A
N/A
Excluded from recovery per client request
What Went Wrong
CC
No further action is required by the N/A pharmacy.
N/A
N/A
Claim should be billed as a compound
CN
CP
Controlled substance prescription (Schedule III and IV substances) filled more than 6 months from date written
No further action is required by the N/A pharmacy; claim will be reversed.
TITLE 21  FOOD AND DRUGS CHAPTER 13  DRUG ABUSE TITLE 21  FOOD AND DRUGS PREVENTION AND CONTROL CHAPTER 13  DRUG ABUSE PREVENTION AND SUBCHAPTER I  CONTROL AND CONTROL A prescription for a controlled ENFORCEMENT SUBCHAPTER I  CONTROL AND ENFORCEMENT substance (Schedule III and IV No further action is required by the Part C  Registration of Part C  Registration of Manufacturers, Distributors, substances) was filled and billed pharmacy; claim will be Manufacturers, Distributors, and and Dispensers of Controlled Substances more than 6 months from the date recouped. Dispensers of Controlled Sec. 829. Prescriptions written on the original prescription. Substances (b) Schedule III and IV substances Sec. 829. Prescriptions (b) Schedule III and IV link: www.usdoj.gov/dea/pubs/csa/829.htm substances
N/A
N/A
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 115 Sec. 5. (a)(6)(C)
Audit cancelled
The prescription was written as a compound however, the pharmacy did not bill it as a compound.
The pharmacy indicates that there No further action is required by the is no record of the prescription pharmacy; the claim will be N/A and/or patient in their computer recouped. system.
Page 1 of 9
Prudent Rx Proprietary Confidential
Claim does not belong to pharmacy
CL
CE
INFSSA Information For Final Determination Letters
The pharmacy previously billed the No further action is required by the same claim twice (same pharmacy; claim will be N/A medication however, Rx number recouped. and/or date may differ).
Duplicate Claim submitted (same medication, Rx number and/or date may differ)
DC
Where To Look For More Information
Audit Code
DD
DP
DQ
DR
DT
DY
What Was Found
Directions not documented/excessive quantity for day supply
Single Pack item cannot be broken / incorrect days supply submitted for single pack item
Days supply and quantity changed to be consistent with plan parameters and prescriber's directions
Duplicate Rx
Duplicate Therapy; medical justification required
Incorrect days supply submitted; no recoupment however days supply changed based on Dr.'s directions
Prudent Rx Proprietary Confidential
What Went Wrong
INFSSA Information For Final Determination Letters
How To Fix It
Directions on documentation Obtain written verification from the provided did not contain sufficient prescribing physician of the information to determine the N/A directions and/or daily dose quantity needed for the day needed by the patient. supply submitted.
Where To Look For More Information
Pharmacy has the option to submit a Indiana Medicaid Drug Claim The Indiana Medicaid Drug The dru is packa ed in a 3 month Form to Prudent Rx correcting the Claim Form can be found on supply and the claim was not day supply. All refills should be the IHCP Web site at billed for a 3 month supply. corrected and billed with the www.indianamedicaid.com. correct day supply.
Claims should be billed in accordance to plan's day supply allowance. The quantity and day supply were corrected by Prudent Rx to be consistent with plan parameters and prescriber's directions.
The pharmacy should correct the patient's prescription profile before N/A submitting claims for future refills.
The pharmacy previously billed the No further action is required by the same claim twice (same pharmacy; claim will be N/A medication , same Rx number and recouped. same date).
Multiple claims were paid for the same patient in the same month for a drug within the same drug class.
Obtain justification from the prescribing physician of the reasons why the patient is utilizing multiple medications within the same drug class for the same indications.
The pharmacy submitted a claim Prudent Rx changed the days with an incorrect day supply supply to correct patient’s profile. based on the physician's directions Pharmacy must also correct the for use. patient's profile.
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N/A
N/A
Citation of Administrative Code
Indiana Code TITLE 12. HUMAN SERVICES ARTICLE 15. MEDICAID IC 121535.57
N/A
N/A
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES IAC 114 Sec. 4. (a)(1)
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 114 Sec. 4. (a)(1)
AND/OR
Indiana Code TITLE 12. HUMAN SERVICES ARTICLE 15. MEDICAID IC 121535.57
N/A
The claim submitted has been submitted correctly however, Confirm that the patient's profile Prudent Rx has identified the claim has been updated so when as an initial dose. Prudent Rx will subsequent refills are dispensed, examine subsequent refills to the correct ongoing dose is ensure the quantity submitted is dispensed and billed as intended based on the continuin dose and by the prescriber. not the initial dose.
Quantity dispensed based on initial dose documented on Rx
IW
Where To Look For More Information
No further action is required by the N/A pharmacy.
Claim excluded from recovery
ID
N/A
FE
ER
Early refill
Pharmacy submitted a refill prior to The pharmacy must provide 75% usage of the previous fill. justification for the early refill.
N/A
N/A
Indiana Code TITLE 12. HUMAN SERVICES ARTICLE 15. MEDICAID IC 121535.57
N/A
N/A
Indiana Code TITLE 12. HUMAN SERVICES ARTICLE 15. MEDICAID IC 121535.57
Citation of Administrative Code
N/A
N/A
Quantity exceeds maximum daily dose for days supply submitted
ED
Audit Code
What Was Found
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 114 Denial of claim payment; basis; discretion of assistant secretary (1) The services claimed cannot be documented by the provider in accordance with 405 IAC 151.
N/A
N/A
How To Fix It
Correct the pharmacy's computer system to reflect the correct quantity for the single package item for all future fills.
N/A
Validate the claim submission to ensure the correct information was submitted. If incorrect data was The Indiana Medicaid Drug submitted, the pharmacy has the Claim Form can be found on option to submit an Indiana the IHCP Web site at Medicaid Drug Claim Form to www.indianamedicaid.com. Prudent Rx assigning a unique Rx number.
The pharmacy submitted a quantity that does not correspond to the FDB indicated quantity of the single package.
One Rx submitted with 2 different patients and/or medications
INFSSA Information For Final Determination Letters
Obtain a letter from the prescribing physician documenting the physician's authorization for the interchange of medication.
The pharmacy submitted two claims with the same prescription number however the patient ID/medications submitted are different.
Prudent Rx Proprietary Confidential
Page 3 of 9
Obtain a letter from the prescribing physician verifing the daily dosage.
What Went Wrong
IQ
The quantity submitted exceeds the maximum daily dose for the days supply submitted and directions do not support the quantity billed.
The prescription provided reflects a drug billed/NDC submitted that is different than that prescribed.
Invalid quantity billed for single package item, days supply may be incorrect
EC
Drug billed is different than that dispensed/prescribed
NR
Prudent Rx Proprietary Confidential
What Was Found
How To Fix It
Audit Code
Package size submitted does not match Package size dispensed
N/A
The pharmacy failed to respond to The pharmacy must provide audit requests and did not provide copies of prescriptions and/or documentation required to signature logs requested by validate claims submitted. Prudent Rx.
Citation of Administrative Code
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 5248 Prior authorization; brand name drugs
Indiana Board of Pharmacy Law, 856 IAC 1312
ND
Pharmacy has the option to submit a Indiana Medicaid Drug Claim The Indiana Medicaid Drug Form to Prudent Rx using the Claim Form can be found on correct NDC number. All refills the IHCP Web site at should be corrected and billed www.indianamedicaid.com. with the correct NDC number.
Information Maintained by the Office of Code Revision Indiana Legislative Services Agency Article 26 (www.in.gov/legislative/ic/cod e/title25/)
The pharmacy billed the wrong NDC number for the package size used to fill the prescription.
Where To Look For More Information
N/A
Pharmacy Failed to Respond in Allotted Timeframe
The prescription must be signed on the Dispense as Written line and “Brand Medically Necessary” must be handwritten by the prescriber Prescription is for a Narrow on the hard copy prescription. Therapeutic Index (NTI) or Mental Health medication submitted with Provider Bulletin BT200132 OR a DAW6. The prescription does not meet DAW6 use requirements. Obtain a letter from the prescribing physician documentin the physician's intent to indicate Dispense as Written.
No Adjustment
What Went Wrong
The hardcopy prescription is identified as a facsimile and is missing one or more of the required facsimile elements to constitute a valid prescription.
NA
856 IAC 1312
Page 4 of 9
Incorrect or invalid DAW / DNS submitted
NS
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER MANUAL: Chapter 9: Pharmacy TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND Services:Libraray Reference SOCIAL SERVICES 405 IAC 152 Sec. 2. Number PRPR10004 (Revision Date March 2009 Version 8.1)
MF
Faxed prescription is found to be incomplete; missing required fax elements
INFSSA Information For Final Determination Letters
OR
N/A
The pharmacy should obtain a new written prescription
No further action is required by the N/A pharmacy.
OR
A letter from the prescribing physician obtaining verification of the authorization of prescription.
No further action is required by the pharmacy; information will be N/A submitted to INFSSA.
RD
Incorrect patient information submitted
N/A
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 151 Sec. 1. (b)(4)
P
PE
Audit Code
What Was Found
N/A
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 151 Sec. 1. (b)(4)
Prudent Rx Proprietary Confidential
The pharmacy has subsequently Pharmacy closed/sold and Rx's are closed it's doors or sold and the unavailable prescriptions are not available for review.
PC
The original prescription is missing the complete date written by the prescriber.
The quantity billed is excessive for The pharmacy must correct the the day supply submitted. Prudent prescription profile for future refills. Rx has reduced the quantity to Claims must be billed in correlate to the directions accordance to INFSSA day supply documented on the prescription allowance and/or the authorized and/or the authorized quantity as quantity as written on the written on the prescription. prescription.
The prescription is dated after the dispense date
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 114 Sec. 4. (a)(4)
Based on the documentation submitted by the pharmacy, the claim was submitted prior to receiving valid authorization from the prescribing physician.
PT
Q
Excessive quantity billed for days supply submitted
Rx is incomplete; Rx date is missing/incomplete
The patient's name on the The pharmacy has the option to prescription is different then submit a Indiana Medicaid Drug The Indiana Medicaid Drug patient's name submitted on the Claim Form to Prudent Rx with the Claim Form can be found on claim. It appears that the patient's correct patient ID number. All refills the IHCP Web site at ID number was submitted should be corrected and billed www.indianamedicaid.com. incorrectly. with the correct patient ID.
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 151 Sec. 1. (b)(2)
Citation of Administrative Code
How To Fix It
INFSSA Information For Final Determination Letters
What Went Wrong
Invalid physician ID
Where To Look For More Information
Obtain a letter from the prescribing physician authorizing the filling of the prescription. The N/A documentation submitted must contain all elements required on a valid prescription.
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER MANUAL: Chapter 9: Pharmacy Indiana Code TITLE 12. HUMAN SERVICES ARTICLE 15. Services:Libraray Reference MEDICAID IC 121535.57 Number PRPR10004 (Revision Date March 2009 Version 8.1)
The pharmacy may obtain a letter from the prescribing physician verifying the date the prescription was written.
Page 5 of 9
The pharmacy submitted the the ID number of a prescriber that is different from the the ID number of The pharmacy has the option to the prescribing physician. submit a Indiana Medicaid Drug The Indiana Medicaid Drug Claim Form to Prudent Rx with the Claim Form can be found on ORcorrect provider ID number. All the IHCP Web site at refills should be corrected and www.indianamedicaid.com. The pharmacy submitted an billed with the correct provider ID. incorrect dummy ID for an outof state prescriber.
RM
IC 25261325 Sec. 25. (d)(6)(B)
Citation of Administrative Code
What Went Wrong
RE
This Rx exceeds allowed refills
RI
Rx is incomplete; Patient name is incomplete/ambiguous
RP
Where To Look For More Information
INFSSA Information For Final Determination Letters
The prescription submitted is Rx is incomplete; Missing Prescriber incomplete. The prescriber Information/ Prescriber Signature/ information is missing to validate it Authorizing Agent/ DEA/ NPI as a legitimate prescription.
Rx is incomplete; Missing more than one required component
The pharmacy may obtain a letter from the prescribing physician containing verification of all the prescription elements that are required.
N/A
The ori inal prescription authorized a refill however all of the The pharmacist shall document authorized refills have been the dates and times that the dispensed. pharmacist attempted to contact the prescribing practitioner or the N/A OR practitioner's designee for consultation and authorization of The pharmacy refilled a the prescription refill. prescription for a controlled substance (schedule II)
link: www.in.gov/legislative/ic/code/title25/ar26/ch13.ht ml
link: www.usdoj.gov/dea/pubs/csa/829.htm
The prescription submitted is incomplete. There is more than one element missing to validate it as a legitimate prescription.
Prudent Rx Proprietary Confidential
TITLE 21  FOOD AND DRUGS CHAPTER 13  DRUG ABUSE PREVENTION AND CONTROL SUBCHAPTER I  CONTROL AND ENFORCEMENT Part C  Registration of Manufacturers, Distributors, and Dispensers of Controlled Substances Sec. 829. Prescriptions (a) Schedule II substances
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 151 Sec. 1. (b)
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 151 Sec. 1. (b)(1)
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 151 Sec. 1. (b)(2)
OR
The pharmacy may obtain a letter from the prescribing physician containing verification of the N/A missing prescription element that is required.
Audit Code
What Was Found
The pharmacy may obtain a letter The prescription submitted is from the prescribing physician incomplete. The patient's name is containing verification of the N/A illegible and/or missing to validate missing prescription element that is it as a legitimate prescription. required.
How To Fix It
Page 6 of 9
Pharmacy must provide a photocopy of the prescription and/or documentation requested.
S
The pharmacy may obtain a letter from the prescribing physician The pharmacy submitted multiple authorizing the reduction in the Unnecessary quantity reduction by claims for quantities less than what quantity originally prescribed N/A pharmacy was prescribed without and/or valid justification for the justification. multiple claims submitted for quantities less than prescribed.
RX
Copy of Rx NOT provided
RS
What Went Wrong
What Was Found
Audit Code
RR
The pharmacy submitted a copy Copy of Rx/documentation is of prescription that was either ille ible; Phcy must provide le ible faded, blurry and/or completely photocopy of Rx/documentation black therefore it is unable to be read.
Where To Look For More Information
Page 7 of 9
The pharmacy failed to provide photocopies of the requested prescription/documentation.
RQ
Prudent Rx Proprietary Confidential
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 151 Sec. 1. (a)
Rx in storage; Unavailable for review
The pharmacy failed to provide photocopies of the requested prescription/documentation.
Returntostock prescription
RT
The pharmacy has indicated that No further action is required by the the claim is for a prescription that pharmacy; claim will be N/A has been returntostock and claim recouped. has not been reversed.
Citation of Administrative Code
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES IAC 114 Sec. 4. (a)(1)
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES IAC 114 Sec. 4. (a)(1)
Pharmacy must provide a photocopy of the prescription and/or documentation requested.
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES 405 IAC 151 Sec. 1. (b)(6)
The pharmacy may obtain a letter from the prescribing physician containing verification of the N/A missing prescription element that is required.
How To Fix It
Pharmacy must provide legible photocopy of the prescription N/A and/or documentation requested.
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER MANUAL: Chapter 9: Pharmacy TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND Services:Libraray Reference SOCIAL SERVICES 405 IAC 152 Sec. 2. Number PRPR10004 (Revision Date March 2009 Version 8.1)
The prescription submitted is Rx is incomplete; Missing directions incomplete. There is more than for use, drug name, strength one element missing to validate it and/or quantity as a legitimate prescription.
INFSSA Information For Final Determination Letters
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER MANUAL: Chapter 9: Pharmacy TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND Services:Libraray Reference SOCIAL SERVICES 405 IAC 152 Sec. 2. Number PRPR10004 (Revision Date March 2009 Version 8.1)
Audit Code
SD
SL
TR
What Was Found
Missing Signature Log; Patient declaration required to validate receipt of Rx
No signature on claim log; Patient declaration required to validate receipt of Rx
The written prescription does not meet CMS tamperresistant requirements
Prudent Rx Proprietary Confidential
What Went Wrong
The pharmacy failed to provide photocopies of the requested signature log/documentation.
INFSSA Information For Final Determination Letters
How To Fix It
A patient declaration must be submitted to validate the receipt of the medication.
Based on a review of the si nature log, there is no recipient signature A patient declaration must be on the claim log validating that submitted to validate the receipt the prescription was received by of the medication. the recipient.
The written prescription does not meet tamperresistant requirements.
Where To Look For More Information
Citation of Administrative Code
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER MANUAL: Chapter 9: Pharmacy Industry standard of practice Services:Libraray Reference Number PRPR10004 (Revision Date March 2009 Version 8.1)
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER MANUAL: Chapter 9: Pharmacy Industry standard of practice Services:Libraray Reference Number PRPR10004 (Revision Date March 2009 Version 8.1)
If the prescription was not written on an Indiana Board of Pharmacy security Rx blank, the prescription pad must contain the following 3 characteristics: 1) one or more industryreco nized features designed to prevent Provider Bulletin BT200724 unauthorized copying of a completed or blank prescription OR form (e.g. thumb print Rx, watermark paper, etc.); INDIANA HEALTH COVERAGE 2) one or more industryreco nized Indiana Board of Pharmacy Law, 856 IAC 1342(b), PROGRAMS PROVIDER features designed to prevent the MANUAL: Chapter 9: Pharmacy erasure or modification of Services:Libraray Reference information written on the Number PRPR10004 (Revision prescription by the prescriber (e.g. Date March 2009 Version 8.1) quantity box, quantities entered in both alpha and numerical format, indelible ink, etc.); 3) one or more industryreco nized features designed to prevent the use of counterfeit prescription forms (see above examples)
Page 8 of 9
Audit Code
UR
What Was Found
What Went Wrong
The pharmacy did not properly document the authorization of additional refills. Refill authorization documentation needed for requested date of OR service Refills are not allowed for by the physician as documented on the prescription.
Prudent Rx Proprietary Confidential
INFSSA Information For Final Determination Letters
How To Fix It
No further action is required by the pharmacy; the claim will be N/A recouped.
Page 9 of 9
Where To Look For More Information
Citation of Administrative Code
Indiana Code CHAPTER 13. REGULATION OF PHARMACISTS AND PHARMACIES . CREATION OF BOARD IC 25261325 Sec. 25. (c)
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