By Sarah Dean, Team Lead, Net-Rx, and Jennifer Gordon, Product Lead, Net-Rx
Some situations require a pharmacist to submit
a claim that, under normal circumstances, would be rejected by the third-party payer. For example, a patient is going on a vacation
and requests a three-month supply of their medication. Submitting this claim without an explanation
will cause the claim to be rejected as a “refill too soon”. To prevent
rejection, this claim must be submitted with a Submission Clarification Code.
Submission Clarification Codes (SCC) are added to a claim before
submission (or resubmission) to provide the third-party payer with further
details about the dispensing event. They are used to proactively prevent or
override claim rejections.
The SCC should be entered in field 420-DK (a universal field in
pharmacy software systems) under the individual claim transaction. A maximum of three codes may be submitted on
an individual claim if more than one code is needed.
There are over 30 defined Submission Clarification Codes; below is
a list of some of the more commonly used codes. SCCs are
defined and published by the National Council for Prescription Drug Programs (NCPDP),
and a complete list can be found on the External Codes List on the NCPDP member-only
portal.
CODE | DEFINITION |
03 | Vacation
Supply: the pharmacist is indicating the cardholder has requested a vacation
supply of the medication |
04 | Lost
Prescription: the pharmacist is indicating the cardholder has requested a
replacement of medication that has been lost |
05 | Therapy
Change: the pharmacist is indicating the physician has determined a change in
therapy was required |
07 | Medically
Necessary: the pharmacist is indicating that this medication has been
determined by the physician to be medically necessary |
08 | Process
compound for approved ingredients |
12 | DME
Replacement Indicator |
13 | Payer-Recognized
Emergency/Disaster Assistance Request: the pharmacist is indicating that an
override is needed base on an emergency/disaster situation recognized by the
payer |
19 | Med
A Split Billing |
20 | 340B:
the pharmacist is indicating that the product being billed was purchased
pursuant to rights available under Section 340B of the Public Health Act of
1992 |
21 | LTC
Dispensing: 14 days or less NOT applicable due to CMS exclusion, manufacturer packaging, or special
dispensing methodology. Medication quantities are dispensed as billed |
22 | LTC
Dispensing: 7 days |
23 | LTC
Dispensing: 4 days |
24 | LTC
Dispensing: 3 days |
25 | LTC
Dispensing: 2 days |
26 | LTC
Dispensing: 1 day |
34 | LTC
Dispensing: 14 days |
35 | LTC
Dispensing: 8-14 day dispensing not listed above |
36 | LTC
Dispensing: Dispensed outside of short cycle. Claim was originally submitted
to a payer other than Medicare Part D and was subsequently determined to be
Part D |
Click Here to See How Identifying Payer Messages Can Help You Comply With Transition Supply Requirements Efficiently
There are SCCs specific to long-term care (LTC) dispensing, as
well as to retail and other classes of trade. The use of SCCs are especially
important for pharmacies servicing LTC facilities, and play a big role in short-cycle
rules and reimbursement from third-party payers.
For example, a long-term care pharmacy that bills post-consumption
(billing that is performed after a drug is dispensed) may dispense the same
drug to a patient multiple times in a month but only adjudicate once. The
pharmacy may be entitled to the full dispense fee for each time the medication
was dispensed. The use of an appropriate SCC can communicate to the third-party
payer how the claim was dispensed, resulting in proper reimbursement.
At Net-Rx™, a provider of reimbursement solutions exclusively for
pharmacies, we recommend pharmacies review how they are using submission
clarification codes every month to ensure proper use and to correct
inappropriate coding from being submitted on future fills. Submitting an
incorrect SCC may cause the claim to be denied or paid incorrectly. Additionally,
incorrect coding might increase the risk of an audit by third-party payers.
There are multiple reports available from Net-Rx that list claims
submitted with one or more SCCs. The
Claims Data Extract tool, part of Net-Rx’s advanced business analytics platform,
Metric-Rx®, allows you to search your adjudicated claims data by specific
criteria, such as SCC.
EditRx, Net-Rx’s enhanced claims editing service, provides reports
that list claims with Submission Clarification Codes and the corresponding quantity
and day supply submitted.
This information along with guidance from Net-Rx’s pharmacy
reimbursement trained analysts can help keep your pharmacy be aware of and
active in best practices for submitting SCCs.
Read more articles that cover topics such as Average Wholesale Price and pharmacy success through COVID-19.
REFERENCES:
https://www.computertalk.com/navigating-short-cycle-billing/
https://www.ncpdp.org/NCPDP/media/pdf/VersionDQuestions.pdf
https://www.resdac.org/cms-data/variables/submission-clarification-code
https://ncpdp.org/About-Us/FAQ
https://www.net-rx.com/Products/Metric-Rx/
https://www.net-rx.com/Products/EditRx/
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2020 Managed Health Care Associates, Inc.