Submission Clarification Codes Decoded

Understanding what Submission Clarification Codes (SCCs) are and how they should be utilized by the pharmacy will help you accurately bill for prescription claims in order to receive maximum reimbursement and avoid costly audit triggers. This knowledge is important so that third-party payers understand the reason for the claims submission (or resubmission).

But first, let’s understand what an SCC is, then we’ll explain its impact on your pharmacy.

What is an SCC?
SCCs are used by the pharmacy to clarify claim processing details and pertain to all classes of trade. These numeric codes are added to claims before submission (or resubmission) in order to, among other things:

• Provide the third-party payer with further details about the dispensing event 
• Clarify the claim submission details so the pharmacy receives proper reimbursement
• Help avoid negative outcomes from payer and regulatory audits
• Proactively prevent or override claim rejections
• Ensure claim accuracy
• Help create an efficient pharmacy workflow

When Should SCCs Be Used?
Below are the most common circumstances when SCCs should be used:

• To override refill-too-soon rejections
• To explain to the payer why claims are being filled early:
  o   Lost or damaged medication
  o   Therapy change
  o   Vacation supplies
• Medical necessity requirements
• Split bills
• Compound ingredient specifications

SCCs and Short-Cycle Billing
In long-term care settings, federal regulations require SCCs for short-cycle billing. SCCs are necessary to explain the strict drug inclusion or exclusion rules and day supply requirements involved with this type of billing. To learn more about short-cycle rules and common codes and definitions, read Are Short-Cycle Rules Giving You A Headache?

Where is the SCC populated?
The SCC should be entered in field 420-DK (a universal field within all pharmacy dispensing software systems) under the individual claim transaction. This field is transmitted to the third-party payer during claim submission (or resubmission). 

What if I have more than one SCC on an individual claim?
If more than one SCC is necessary, a maximum of three may be submitted. Any time field 420-DK is populated by the pharmacy, field 354-NX (SCC Count) must also be populated, to inform the third-party payer as to the exact number of SCCs being utilized.

How many SCCs are there?
There are over 50 SCCs, defined and published by the National Council for Prescription Drug Programs (NCPDP). ¹ A complete list can be found on the External Codes List on the NCPDP member-only web portal. 

Gain exclusive access to a list of the most common codes utilized in pharmacy billing along with their definitions here.

Reimbursement
When a prescription claim is billed incorrectly, it can result in reimbursement that is lower than the contracted amount. Contracts with payers hold both the payer and the pharmacy accountable for the obligations defined within them. The pharmacy must follow coding and claim submission rules to receive the reimbursement outlined in those contracts, and the payer must reimburse at the contracted rate when claim submission rules are followed accurately.

Dispensing a prescription may seem straightforward, but billing procedures can be complex and the pharmacy must ensure they code the claim accurately in order to receive the correct reimbursement. For example, if the pharmacy physically dispenses a prescription multiple times but bills the payer one time for all dispenses of that prescription, the pharmacy may be eligible to receive multiple dispensing fees from the payer. However, the pharmacy must utilize the correct SCC to communicate this to the payer in order to receive the appropriate payment.

Download the SCC Reference Chart to see the correct code to use for this example.

Audit Impact
Claim audits can negatively impact the pharmacy financially and cost precious time and labor. Reimbursement is dependent on accurate claim submission. If a claim is reimbursed at the contracted rate, but later determined by an audit to have included errors, the reimbursement the pharmacy already received can be recouped or taken back by the payer. For example, if a pharmacy uses SCC 05 (therapy change) to override a refill-too-soon rejection but does not include documentation to support the therapy change, the payer can recoup the amount they have already reimbursed the pharmacy.  

In addition to payer audits, pharmacies can be audited by government agencies to ensure they are abiding by federal regulations pertaining to skilled nursing facility and other LTC billing practices. An example would be using short-cycle exclusion codes such as SCC 21 or SCC 36 on claims that should have been short-cycled. If errors are discovered by these agencies, the pharmacy is subject to take backs, fines and potential closures.

Workflow Impact and Rejections
Understanding SCC usage requirements and properly implementing SCCs ensure claims are processed accurately the first time. Rejections caused by billing errors or incorrect or blank SCCs cause re-work and significant disruptions to a pharmacy’s workflow and also can delay the delivery of patients’ medications. Using SCCs help to streamline the workflow and save time and money by reducing labor and transaction fees that are accrued each time a claim is submitted. Claim submission accuracy also allows the pharmacy to focus on providing the best patient care and support.

SCCs and pharmacy billing are complex, but it is possible to manage them efficiently.

At Net-Rx ^TM , there are several solutions that help pharmacies identify the appropriate SCCs to use, to ensure your pharmacy accurately bills every prescription claim, receiving maximum reimbursement and workflow efficiency while avoiding costly audit triggers:

• Analyst Support:   Guidance from the pharmacy reimbursement trained analysts at Net-Rx can help ensure your pharmacy is following best practices relating to the usage of SCCs.
• Script-IQ ^® :  A pre-edit solution including a configurable rule to alert your pharmacy of SCC discrepancies within your short-cycle related claims before they are submitted to the third-party payer. This allows you to get it right the first time, prior to adjudication, while protecting against common SCC audit triggers.
• EditRx:   The SCC report provides your pharmacy with visibility into all claims submitted with SCCs. With this report you can confirm that your pharmacy is utilizing SCCs with the corresponding quantity and day supply correctly. With claim details at your fingertips, you can make corrections where appropriate, ensure documentation is properly included and follow-up is performed on refills as necessary.
• Metrix-Rx ^® :   Within the business analysis tool, there are additional ad-hoc reports that allow you to search your adjudicated claims data using specific criteria, such as SCC. The ultimate goal is to ensure accurate billing for proper reimbursement and efficient pharmacy workflow.

SCCs are an integral part of pharmacy billing and workflow. Knowing what they are, when to use them, and how to use them accurately may have a positive impact on a pharmacy’s bottom line. With automated solutions from Net-Rx, they can help you achieve maximum reimbursement, workflow efficiency, and reduced audit risk. Be sure to download our SCC Reference Chart and contact Net-Rx for a demo on our solutions today.

Reference

1. https://ncpdp.org

Authors

Jennifer Gordon  Product Lead Joined Net-Rx in December 2013

Jennifer Gordon is intimately involved with bringing new technology products and services to the marketplace to provide solutions for pharmacies’ business needs. Her philosophy is to learn as much as she can to improve pharmacies’ business journey and better the industry’s health. Jennifer’s career in pharmacy began 2009 as a CPhT technician. Her love of pharmacy operations drove her to work hard to ensure the pharmacy ran smoothly and patient care was held to the highest quality standard. To further her education, Jennifer earned her Associates of Science degree in 2012 and thrived on the knowledge and experience she gathered throughout the healthcare industry. She then acquired her billing and reimbursement certification from the Pharmacy Technician Certification Board. Jennifer began her career at MHA as an Account Analyst responsible for managing accounts across the nation by providing guidance, education, and training to ensure pharmacies were operating efficiently to receive maximum reimbursement. Her abilities and successes were recognized and rewarded in her promotions to Team Lead and then to Product Lead, where she currently manages all Net-Rx portfolio products.

Wanda Lund  Product Lead Joined Net-Rx in 2009

With over 20 years of pharmacy experience, Wanda’s extensive industry knowledge includes retail and long-term care pharmacy pricing, contracting, billing, reimbursement, analytics, and structuring technology platforms. As Product Lead, her skills play an essential role in her daily responsibilities to enhance and grow the Net-Rx portfolio of services and solutions. Wanda is passionate about helping pharmacies maximize their business growth, allowing the pharmacy to focus on patient care. She supports various positions from dedicated analysts, developers, product owners, and operations managers to ensure customer satisfaction and build trusting relationships with our customers, partners, and associates. Wanda lives in Central Washington and enjoys the region’s snow in the winter and heat in the summer. She is an avid animal lover, and enjoys watching football, camping, and spending time with family.