Newborn Billing & Eligibility

[sspharmy]

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I work at a pbm and today I received a call from a patient that just had a baby 2 weeks ago. Her baby isn't on the insurance plan yet, but fortunately her plan allows the baby's rx's to be run under the cardholders profile (in this case the mother) for the first two months of life.

I called the retail pharmacy and relayed this information to them and the technician got all huffy and puffy with me when I worded it as "So the pharmacist isn't willing to run it under the mother's profile" etc etc. Poor choice of wording on my part. The technician then proceeded to inform me in a sassy manner that this would be breaking pharmacy laws because the rx has the infants DOB instead of the mothers DOB so therefore the pharmacist would not be able to verify it.

My pbm has pharmacy staff call in regarding newborn eligibility multiple times a week. They all state that an rx has been written for a newborn and they have not been added to the plan yet. As long as it's an applicable benefit of the plan and it's in the acceptable time frame, we tell them it's ok to run it under the cardholders profile and they do and the approved claim shows up in the system instantly.

I'm also a technician at a retail pharmacy and as long as the insurance has verbally OK'd it, my pharmacists have never had a problem running the rx under the cardholders profile and just notate the situation on the rx/in the system.

If this is breaking a law what law is it and what should the Mother do? Should she have the physician rewrite the script under her name and DOB? But then that would be problematic because the medication isn't for her, it's for her infant? Is this more of a breaking the law thing or more of a judgment call thing?

For what it's worth this was a CVS retail pharmacy in Texas and the rx was for an antibiotic.

Thanks for the insight!

 

[Lnsean]

The script must be written for the new born. It cannot be written for the mother. Some rphs wont give af but legally it should be written for the newborn. You tell the pharmacy to create a profile for the newborn and run it through with the mom's insurance and dob...and then change the dob back after the claim has adjudicated. This is to ensure that when the medication is filled...it is filled and processed under the baby's profile. Everything is straight on the pharmacy's end and the pharmacy's ass is covered there. The adjudication details will be off obviously but that is on your end at the pbm (it will show as a claim for the mom on your end). I also annotate on the new born script that he/she is a newborn and that I am processing it through the mom's insurance for auditing purposes. Most rphs will know how to do this or learn to do this with experience, you probably had someone new. Also, I don't do this if its been more than 30 days since birth; it's on the parents to get the baby added. If they present later with a script, I would tell them they need to pay out of pocket and file claim with the insurance manually.

 

[npage148]

In my system we can force bill an insurance with information different than the patients profile. So like if the patients birthday with the insurance is wrong we can bill with that birthday rather than change the real one in the profile. I imagine that's how I'd do it after talking with you. Then all the patients demographic info is still accurate.

But whatever. 2 months is a longtime to deal with something that could be fixed in a week (NYS can manage to get Medicaid cards for newborns days after being born so why can this be that quick) or they can just pay cash and submit themselves.

 

[sspharmy]

Thanks for the responses.

It's a commercial plan and tbh I can't speak for them when it comes to how long it takes them to add eligibility to their system and send that update to ours. Thanks for the info though. Now I have a little bit more knowledge if I run into this same issue in the future.

 

[lord999]

By the way, that's your PBM's own fault, not the pharmacy's for that state of affairs. There's actually an exception that you can put in the Insured's profile for a 30 day no-DOB check for NCPDP transactions. That should have been automatically done with L&D, but this might need to go as an exception upstairs in your place.

 

[sspharmy]

By the way, that's your PBM's own fault, not the pharmacy's for that state of affairs. There's actually an exception that you can put in the Insured's profile for a 30 day no-DOB check for NCPDP transactions. That should have been automatically done with L&D, but this might need to go as an exception upstairs in your place.

Interesting. I’ve never heard of that at my pbm. For majority of our plans the only changes mostof us (including supervisors, pharmacists, and site managers) at our pbm are able to make are those regarding prior auths, dosage increases, and emergency overrides. Any other changes would have to be made by the health plan and sent to our system.

The times I have had to reference the newborn policy it’s been something along the lines of “if no coverage for the newborn is found advise the pharmacy to run claims under then insureds profile for first 1-2 months of life”. Perhaps not all health plans use that exception.

 

[CetiAlphaFive]

I work at a pbm and today I received a call from a patient that just had a baby 2 weeks ago. Her baby isn't on the insurance plan yet, but fortunately her plan allows the baby's rx's to be run under the cardholders profile (in this case the mother) for the first two months of life.
I called the retail pharmacy and relayed this information to them and the technician got all huffy and puffy with me when I worded it as "So the pharmacist isn't willing to run it under the mother's profile" etc etc. Poor choice of wording on my part. The technician then proceeded to inform me in a sassy manner that this would be breaking pharmacy laws because the rx has the infants DOB instead of the mothers DOB so therefore the pharmacist would not be able to verify it.
My pbm has pharmacy staff call in regarding newborn eligibility multiple times a week. They all state that an rx has been written for a newborn and they have not been added to the plan yet. As long as it's an applicable benefit of the plan and it's in the acceptable time frame, we tell them it's ok to run it under the cardholders profile and they do and the approved claim shows up in the system instantly.
I'm also a technician at a retail pharmacy and as long as the insurance has verbally OK'd it, my pharmacists have never had a problem running the rx under the cardholders profile and just notate the situation on the rx/in the system.
If this is breaking a law what law is it and what should the Mother do? Should she have the physician rewrite the script under her name and DOB? But then that would be problematic because the medication isn't for her, it's for her infant? Is this more of a breaking the law thing or more of a judgment call thing?
For what it's worth this was a CVS retail pharmacy in Texas and the rx was for an antibiotic.
Thanks for the insight!

They're an idiot.
Literally who cares, in a corporate setting, what commercial insurance roles are.

Next time just tell them, "that's literally the only thing you can do.

Call your software provider or your state board of pharmacy."

 

[zelman]

that's literally the only thing you can do.

Not really. They can force them to file a paper claim. Which is what most pharmacists do.

 

[Sine Cura]

Maybe the pharmacist assumed it was a Medicaid plan. 99.99% of ped scripts I see are billed to Medicaid. However even managed care plans do permit newborn Rx to be billed using the mother's ID

 

[zelman]

Maybe the pharmacist assumed it was a Medicaid plan. 99.99% of ped scripts I see are billed to Medicaid. However even managed care plans do permit newborn Rx to be billed using the mother's ID

Pharmacists are happy to use mom's ID. Not her DOB.

 

[owlegrad]

You tell the pharmacy to create a profile for the newborn and run it through with the mom's insurance and dob...and then change the dob back after the claim has adjudicated.

This is exactly what I would have done.

 

[trailerpark]

You tell the pharmacy to create a profile for the newborn and run it through with the mom's insurance and dob...and then change the dob back after the claim has adjudicated.

At Walmart when you add an insurance card, in this case adding the mom's insurance to the newborn's profile, there's a field called "insurance dob" that you would put the mom's DOB in so you never have to switch the newborn's DOB back and forth on their own profile. But yeah definitely make a new profile for the baby. I've never heard of filling baby meds under a parent.

 

[Lnsean]

At Walmart when you add an insurance card, in this case adding the mom's insurance to the newborn's profile, there's a field called "insurance dob" that you would put the mom's DOB in so you never have to switch the newborn's DOB back and forth on their own profile. But yeah definitely make a new profile for the baby. I've never heard of filling baby meds under a parent.

Walgreens has no such feature...you have to switch it manually and be competent enough to remember to switch it back.