Bulletinbltn0711.doc by banger18

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									                                                                              Newfoundland and Labrador Prescription Drug Program




                                                                             BULLETIN                                    NO. 12


         Newfoundland and Labrador Prescription Drug Program

                         IMPORTANT NOTICE TO PROVIDERS


Claim Submission Process
Please be advised that NLPDP will be accepting claims from providers as outlined below:

Current Batch System (Electronic)

-      for Plan E (Income Support) and Plan N (Seniors) no changes. To remain as per current process


Current (Old) Special Claim Form (Manual)

-      to be completed by pharmacies for claims for Plan E ( Income Support) and Plan N ( Seniors) ONLY ,
       and ONLY to be completed for coordination of benefits (COB), or price adjustments

-      date of birth and gender are not required on this form for processing (This is a change since the latest
       memo which was enclosed with the February 5, 2007 claim booklet mail-out, as a number of
       vendors indicated difficulty in providing this through the batch adjudication system)


New Regular Claim Form (Manual)

-     to be completed by providers for Low Income claims ONLY

-     date of birth, gender and days supply required (days supply to be written in the right hand margin)


New Special Claim Form (Manual)

-      to be completed for Low Income claims ONLY for coordination of benefits (COB), claim
       resubmissions, reversals and price adjustments (However, it has been suggested that to avoid further
       delay in payment and to minimize the potential for errors a better option would be to hold any
       resubmissions for the Low Income Drug Program until the system is live and submit them
       electronically).


                       P.O. Box 8070, Postal Station ‘A’, St. John’s, NL, Canada A1B 4A6 t 709.753.3615 f 709.739.2929
                                                                               Newfoundland and Labrador Prescription Drug Program




Computer Generated Forms

The new adjudication system will require 3 price fields, one for cost, one for surcharge and one for the fee.
Since a number of pharmacy systems do not have these fields available on the computer generated forms,
submission of claims with a surcharge may result in improper reimbursement. If your vendor’s computer
generated form does not breakout the price in the three fields, and you need to claim a surcharge for claims with
a drug cost over $30.00 or the surcharge for diabetic supplies, you should include the combined drug cost and
surcharge in the drug cost field (the NLPDP has implemented a temporary adjustment to the adjudication
system to compensate for this situation until real-time is operational for all pharmacies).

If your computer generated form does not support the provision of a previously paid amount, you have two
options for claims where the cardholder has other coverage:
     Manually add the previously paid amount to the computer generated form; or
     Use the manual Special Claim form as noted in the previous section.

To date computer generated reports have been reviewed from all the software vendors and the following have
been approved for use in light of the previous adjustment:
    Kroll;
    Propharm
    Walmart
    Shoppers Drug Mart
    Emergis – Assyst RX-T (* a modified report will be provided)
    Emergis – Assyst RX-S (* a modified report will be provided)
    Emergis – Assyst RX-A (* a modified report will be provided)
    Emergis – Assyst RX-Q


When NLPDP's on-line real time system is LIVE in the coming weeks, the new manual special claim forms
will be used for all three plans, Seniors, Income Support and Low Income. HOWEVER, pharmacies can
continue to bill plans E and N via their batch process until they convert to real-time time, with no changes.

When requesting special claim form booklets from NLPDP please be very clear if you need the old or the new
forms for submitting your claims.




                        P.O. Box 8070, Postal Station ‘A’, St. John’s, NL, Canada A1B 4A6 t 709.753.3615 f 709.739.2929
                                                                               Newfoundland and Labrador Prescription Drug Program




Clients Presenting With Two NLPDP Cards
It has come to our attention that a small number of NLPDP clients have received a Low Income Drug Card in
addition to their Income Support or Seniors Drug Cards.

This is occurring because not all of our current clients have had their MCP numbers entered into the system,
which is the last check for current coverage before issuing a Low Income Drug Card. This will become less of
an issue as the system continues to be updated.

If the client has a valid Income Support or Seniors card, pharmacies should bill NLPDP under one of these
programs and advise the client to contact the Stephenville office to have their Low Income card cancelled.


Clarification of Prescription Drug Cost for the Low Income Program
There appears to be some confusion around the definition of “prescription drug cost” under the new program.

Prescription drug cost refers to the total prescription cost as per the NLPDP cost policies (ie defined as: cost
(with applicable manuf markup) + surcharge (if applicable) + NLPDP established fee).


Benefit List for the Low Income Drug Program

As noted in Bulletin # 9, February 1, 2007:

The Low Income Drug Program Benefit List will be the same as for the current Income Support Program (Plan
E). The benefit list has been posted and can be viewed on the following website www.gov.nl.ca/health/nlpdp
and is shown in the benefit table as Plan L. Pharmacies can also dial up to the communications servers to pick
up the Coverage Status Table Listing if they do not have internet access.




                        P.O. Box 8070, Postal Station ‘A’, St. John’s, NL, Canada A1B 4A6 t 709.753.3615 f 709.739.2929
                                                                               Newfoundland and Labrador Prescription Drug Program




Pharmaceutical Services Act
New legislation came into effect January 31, 2007 to govern the Newfoundland and Labrador Prescription Drug
Program (NLPDP) as well as other pharmaceutical programs and services provided by the Department of
Health and Community Services. The Pharmaceutical Services Act provides enhanced transparency and
accountability for the core elements of the Newfoundland and Labrador Prescription Drug Program (NLPDP);
the Tamper Resistant Prescription Pad Program; and the Newfoundland and Labrador Interchangeable Drug
Products Formulary.

The new act provides clarity by defining eligibility requirements and appeals processes for beneficiaries under
the NLPDP as well as the decision-making process for coverage of new drug therapies. Furthermore, the act
gives government the authority necessary to ensure that an effective and efficient audit function is in place to
maintain the financial sustainability of the program.

As well, the legislation introduces a payer of last resort requirement for the NLPDP, requiring individuals with
alternate drug insurance to bill their private insurer first and government last.


The Pharmaceutical Services Act can be viewed at: http://www.hoa.gov.nl.ca/hoa/sr/

ECS070216




                        P.O. Box 8070, Postal Station ‘A’, St. John’s, NL, Canada A1B 4A6 t 709.753.3615 f 709.739.2929

								
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