Walgreens billing questions

[Ezegalan]

Can somebody please explain in simple terms how the heck you bill test strips and diabetic supplies to Medicare properly? I always get these TPR rejects about "CMN form" that I'm not sure how to explain to the customer. All this stuff about chargebacks and diagnosis codes and Medicare supplements and stuff go over right over my head.

Also similar problem with nebulizers and masks. WTF is up with those.

Also, if anyone here works in New Jersey, can someone please explain this whole deal with NJMED and HZMY and FINDINS. It's soooo confusing. Sometimes something's covered, other times it's not. People come in and complain "it's supposed to be free." And then I check the history and see that they paid like $50. I try COB and sometimes it works, sometimes it doesn't. I try SDL and sometimes it works, sometimes doesn't. It's such a huge waste of time.

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[FlavyFlav]

Ok. So for billing diabetic testing supplies and some nebulizer medications to Medicare part B (the red, white, and blue card) you will most times be asked for a certificate of medical necessity (CMN) form to be filled out by the doctor. Medicare allows a once a day testing which should automatically be covered unless the patient is brand new to testing and has never had a claim before.

1) Anything else will require you to call Walgreen's Medicare department. I don't know the number off the top of my head, but you can find it under the MEDICARE insurance information.

2) You will talk to an Indian representative and tell him you require a CMN form for such and such person. Have them fax it to your store, don't have them send it to the doctor directly or it WILL get lost.

3) When you get the form, call the doctor's office and verify who takes care of these things and what fax number they want it sent to, verify a second time. Circle and draw an arrow to all the parts they have to fill out, make sure the doctor knows to SIGN it and date with the correct date.

4) When you send the fax, call the office 30 to 60 minutes later to verify they do indeed have it and remind them it needs all spots filled out that you have circled.

5) When they fax the form back to you, check and make sure it has all been filled out. If not, repeat steps 3 and 4.

6) Scan this form into the patient's profile and call back Walgreen's Medicare department. Let the agent know the form is in their file. You will be told to try rerunning the script in 30 minutes. If it does not work then, call them back.

CMN forms are a headache because it is a time consuming process where so many parts can go wrong. Keeping your staff updated on where you are at and documenting the steps will make it flow more smoothly, but you will still deal with doctors that have no clue where to sign their name. As for nebulizers and masks, Medicare will not cover these through Walgreen's at all, so don't waste your time with billing them.

I cannot answer about your Medicaid as I only deal with Florida Medicaid (a headache in its own right). Hopefully that cleared up that part a bit for you, let me know if you need anything else.

 

[Lnsean]

I would like to add something that most people don't know about Walgreens and billing Medicare; the billing isn't done in real-time. The billing is done later by our medicare department. Some facts to know:

MEDICARE B and Walgreens:

1. Walgreens will let you bill for test-strips and will let it go through the FIRST time a patient gets it filled...if it's 1x/day testing. This does not mean you won't get a charge back. All it means is that Walgreens is willing to take a chance on the script; the 3rd party department will follow up with the doctor and get the necessary CNM form completed. If the 3rd department fails to do this, you will get a rejection when the pt comes back for a refill AND you will get a charge back months later. So many times you look in the history and see that the first time, it was covered. Then when the patient comes in for a refill, you get a CMN rejection. This is because 3rd party has failed to get the paperwork done on their end. This is when you have to call them...request that they fax the CMN form to your store...so you can bug the MD office every day until it's completed. Anything above 1x/day testing will be automatically rejected by 3rd party. This is because it gets very complicated..and depending on dx codes and whether pt is on insulin or not...3rd party feels that it's not worth the risk. They want to see the CMN completed first.

This is the main reason you are seeing chargebacks...because Medicare billing isn't adjudicated in real-time. The paperwork gets done days and months later...and if the dx is not right, you get a charge back. If the 3rd party staff can't get a CMN form back from the MD, it's a charge back. If none of these things/paperwork add up when the 3rd party team goes to do the billing...you will get a chargeback and you will get a rejection on the next refill. Yes, you will take losses for a good number of these but that is the cost of doing business that Walgreens is willing to take.

Medicare B and Supplemental Insurance (Medigap)

Medicare B usually covers about 80% of the cost for patients and they're left with about 20%...this is just a rough estimate. Some patients will choose to purchase additional coverage called Medicare Suppemental Insurance or Medigap policy. This is to supplement their Medicare Part B and is used to pay the copay left over from Part B. You can scan this under "SUPPLEMENTAL/COB" in IC+ when you highlight or click on MEDICARE in 3rd party window. IC+ will allow you to scan 1 card in and use that as COB. Again, the billing is not done in real time. When you do this...it will go through for 0 and if it turns out that whatever you scanned in isn't active or correct, you will get a charge back months later.

NJMED---HZMY (HMO)

1. NJMED is straight medicaid from NJ. Molina is the administrator. Most people when they first sign up for medicaid will have NJMED because they have not been assigned an HMO yet. NJMED will require that you call Molina for a lot of meds to go through. These scripts will often reject for PA needed----but it's not a hard reject. The pharmacist can call Molina and get these overidden. Molina will ask for the last 5 digits of the ICN rejection code and the EDITs code. Most edits can be overridden by just talking to them on the phone. They are only open M-F...8A-5PM. They have pharmacists on call for emergency overrides if you need it.

2. HZMY (HMO). There are 4 Medicaid HMOs in NJ (Horizon, Aetna, United Healthcare, and Amerigroup) and most patients who initially get NJMED will eventually be assigned to one of these four plans. These companies contract with the state to help manage their benefits for New Jersey. When patients are assigned an HMO...their NJMED becomes inactive for pharmacy. You have to bill the HMO. When a patient is eligible for medicaid but also works and has commercial insurance...medicaid becomes secondary and the patient's work insurance becomes primary. You can COB HZMY after billing the patient's private insurance first. I've seen alot of techs and pharmacists that simply tell patients their HZMY is no longer billable because they have another primary and then proceed to only bill their private insurance, so a lot of times I look like an ass correcting them. Many patients have both...and you do bill both. Please do not do this to your patients...it's a great disservice to them. If you don't know...always ask.

Dual Eligible Patients (Medicare D and Medicaid)

1. Medicare D is always primary and the Medicaid HMO is always secondary. With the exception of various OTC products (vitamins), if Medicare D does not cover a drug...then the pt needs to have the MD do a PA. Medicaid will not step in to cover it.

2. For vitamins---Medicaid HMO (HZMY) will step in to pay for OTC vitamins (mainly vit Ds and aspirins) provided that they see a rejection from Medicare first. You can have the system do this automatically by having HZMY as a COB to their primariy part D plan...bill for the vitamin....get the rejection...and hit "bill secondary." After it goes through, you ahve to remember to go back and uncheck the COB box otherwise you will get all these rejections when billing for other meds. Only check the COB box for vitamins...get the claim to go through..and then go back and uncheck it.

The manual way is to bill part D first....get the rejection....leave it in TPR...and SDL it to HZMY.

FINDINS

This is just a tool to help you try to locate or pinpoint a patient's insurance. It works sometimes and most of the time it's useless. Don't fret over it. It's meant to just be an added tool to locate someone's plan as a last ditch effort towards better customer service. It's not your job to find out what insurance the patient has, and try not to make it so...otherwise you'll be on the phone all day.

 

[farmadiazepine]

This is the biggest waste of time.

And Medicare is a joke.

 

[farmadiazepine]

I would like to add something that most people don't know about Walgreens and billing Medicare; the billing isn't done in real-time. The billing is done later by our medicare department. Some facts to know:

MEDICARE B and Walgreens:

1. Walgreens will let you bill for test-strips and will let it go through the FIRST time a patient gets it filled...if it's 1x/day testing. This does not mean you won't get a charge back. All it means is that Walgreens is willing to take a chance on the script; the 3rd party department will follow up with the doctor and get the necessary CNM form completed. If the 3rd department fails to do this, you will get a rejection when the pt comes back for a refill AND you will get a charge back months later. So many times you look in the history and see that the first time, it was covered. Then when the patient comes in for a refill, you get a CMN rejection. This is because 3rd party has failed to get the paperwork done on their end. This is when you have to call them...request that they fax the CMN form to your store...so you can bug the MD office every day until it's completed. Anything above 1x/day testing will be automatically rejected by 3rd party. This is because it gets very complicated..and depending on dx codes and whether pt is on insulin or not...3rd party feels that it's not worth the risk. They want to see the CMN completed first.

This is the main reason you are seeing chargebacks...because Medicare billing isn't adjudicated in real-time. The paperwork gets done days and months later...and if the dx is not right, you get a charge back. If the 3rd party staff can't get a CMN form back from the MD, it's a charge back. If none of these things/paperwork add up when the 3rd party team goes to do the billing...you will get a chargeback and you will get a rejection on the next refill. Yes, you will take losses for a good number of these but that is the cost of doing business that Walgreens is willing to take.

Medicare B and Supplemental Insurance (Medigap)

Medicare B usually covers about 80% of the cost for patients and they're left with about 20%...this is just a rough estimate. Some patients will choose to purchase additional coverage called Medicare Suppemental Insurance or Medigap policy. This is to supplement their Medicare Part B and is used to pay the copay left over from Part B. You can scan this under "SUPPLEMENTAL/COB" in IC+ when you highlight or click on MEDICARE in 3rd party window. IC+ will allow you to scan 1 card in and use that as COB. Again, the billing is not done in real time. When you do this...it will go through for 0 and if it turns out that whatever you scanned in isn't active or correct, you will get a charge back months later.

NJMED---HZMY (HMO)

1. NJMED is straight medicaid from NJ. Molina is the administrator. Most people when they first sign up for medicaid will have NJMED because they have not been assigned an HMO yet. NJMED will require that you call Molina for a lot of meds to go through. These scripts will often reject for PA needed----but it's not a hard reject. The pharmacist can call Molina and get these overidden. Molina will ask for the last 5 digits of the ICN rejection code and the EDITs code. Most edits can be overridden by just talking to them on the phone. They are only open M-F...8A-5PM. They have pharmacists on call for emergency overrides if you need it.

2. HZMY (HMO). There are 4 Medicaid HMOs in NJ (Horizon, Aetna, United Healthcare, and Amerigroup) and most patients who initially get NJMED will eventually be assigned to one of these four plans. These companies contract with the state to help manage their benefits for New Jersey. When patients are assigned an HMO...their NJMED becomes inactive for pharmacy. You have to bill the HMO. When a patient is eligible for medicaid but also works and has commercial insurance...medicaid becomes secondary and the patient's work insurance becomes primary. You can COB HZMY after billing the patient's private insurance first. I've seen alot of techs and pharmacists that simply tell patients their HZMY is no longer billable because they have another primary and then proceed to only bill their private insurance, so a lot of times I look like an ass correcting them. Many patients have both...and you do bill both. Please do not do this to your patients...it's a great disservice to them. If you don't know...always ask.

Dual Eligible Patients (Medicare D and Medicaid)

1. Medicare D is always primary and the Medicaid HMO is always secondary. With the exception of various OTC products (vitamins), if Medicare D does not cover a drug...then the pt needs to have the MD do a PA. Medicaid will not step in to cover it.

2. For vitamins---Medicaid HMO (HZMY) will step in to pay for OTC vitamins (mainly vit Ds and aspirins) provided that they see a rejection from Medicare first. You can have the system do this automatically by having HZMY as a COB to their primariy part D plan...bill for the vitamin....get the rejection...and hit "bill secondary." After it goes through, you ahve to remember to go back and uncheck the COB box otherwise you will get all these rejections when billing for other meds. Only check the COB box for vitamins...get the claim to go through..and then go back and uncheck it.

The manual way is to bill part D first....get the rejection....leave it in TPR...and SDL it to HZMY.

FINDINS

This is just a tool to help you try to locate or pinpoint a patient's insurance. It works sometimes and most of the time it's useless. Don't fret over it. It's meant to just be an added tool to locate someone's plan as a last ditch effort towards better customer service. It's not your job to find out what insurance the patient has, and try not to make it so...otherwise you'll be on the phone all day.

Very thorough and informative! Thank you!

I don't work at Walgreens, but I do work at an independent, and I learned something here.

 

[okieboba]

FWIW, nebulizers aren't covered but their related solutions are, as long as the proper CMN form is filled out correctly.

As of a month or 2 ago, Medicare (or Walgreens) requires the date of the machine purchased or rented on file, and you do this through storenet under medicare tab (I forget where but you can find info on Compass). Ask the patient but, more times than not, they will either not remember or say its been a few years. So, you can either come to an agreement with the patient on what date to put down (you only need month/year) or have them buy a new one (lol?).

 

[coconutwata]

What does it mean when the rejection states,

"Host ineligibilty error"

"NDC not covered"

"Invalid Diagnosis Code-Review Reference Window",Pt ineligibile for this HCPCS" the medication was Test strips. (medicare covered it in previous months but now it's giving this message.
Primary Plan-Medicare: rejected Secondary Plan-MEDCOB: Not billed yet

How do I double bill?

 

[BidingMyTime]

1. Walgreens will let you bill for test-strips and will let it go through the FIRST time a patient gets it filled...if it's 1x/day testing. This does not mean you won't get a charge back. All it means is that Walgreens is willing to take a chance on the script;

My understanding was that this is a Medicare requirement, that a pharmacy *must* fill the first strip RX given to them, even though they might get a charge-back if the CMN isn't approved.

 

[Lnsean]

My understanding was that this is a Medicare requirement, that a pharmacy *must* fill the first strip RX given to them, even though they might get a charge-back if the CMN isn't approved.

This may very well be true and I have heard of that. I have never read anything about such a requirement...I've only casually heard about it popped up sometimes. In practice, I can tell you that is not what is happening, so there is definitely other details to that requirement (exceptions to the rule like if it's 3-4x testing).

Others can chime in on this too...I'd love to hear if this "rule" is out there and what CVS/WAGS are doing because if you try to process a rx for 3-4x testing even on the first script...it's going to reject.

 

[PangoPillPusher]

This may very well be true and I have heard of that. I have never read anything about such a requirement...I've only casually heard about it popped up sometimes. In practice, I can tell you that is not what is happening, so there is definitely other details to that requirement (exceptions to the rule like if it's 3-4x testing).

Others can chime in on this too...I'd love to hear if this "rule" is out there and what CVS/WAGS are doing because if you try to process a rx for 3-4x testing even on the first script...it's going to reject.

No reject here for 3-4x testing. We just have to fax an overutilization form into the Dr, they fill it out for why they have to test more often and then we put that into their med dme file.

Sent from my VS995 using Tapatalk

 

[pharmaking]

This may very well be true and I have heard of that. I have never read anything about such a requirement...I've only casually heard about it popped up sometimes. In practice, I can tell you that is not what is happening, so there is definitely other details to that requirement (exceptions to the rule like if it's 3-4x testing).

Others can chime in on this too...I'd love to hear if this "rule" is out there and what CVS/WAGS are doing because if you try to process a rx for 3-4x testing even on the first script...it's going to reject.

WAGS: when billing Medicare, if md writes for 30 day supply test (1,2,3 or 4 etc..)times a day testing I get a reject that we must bill for 90 days, in my state we have to get a new rx for 90 day script even if the 30 day script has plenty refills... sometimes more BS occurs where then CMN form is required.... etc etc... I personally never saw many or any CMN form rejections until middle of 2016 having worked only since mid 2015.

 

[pharmaking]

I would like to add something that most people don't know about Walgreens and billing Medicare; the billing isn't done in real-time. The billing is done later by our medicare department. Some facts to know:

MEDICARE B and Walgreens:

1. Walgreens will let you bill for test-strips and will let it go through the FIRST time a patient gets it filled...if it's 1x/day testing. This does not mean you won't get a charge back. All it means is that Walgreens is willing to take a chance on the script; the 3rd party department will follow up with the doctor and get the necessary CNM form completed. If the 3rd department fails to do this, you will get a rejection when the pt comes back for a refill AND you will get a charge back months later. So many times you look in the history and see that the first time, it was covered. Then when the patient comes in for a refill, you get a CMN rejection. This is because 3rd party has failed to get the paperwork done on their end. This is when you have to call them...request that they fax the CMN form to your store...so you can bug the MD office every day until it's completed. Anything above 1x/day testing will be automatically rejected by 3rd party. This is because it gets very complicated..and depending on dx codes and whether pt is on insulin or not...3rd party feels that it's not worth the risk. They want to see the CMN completed first.

This is the main reason you are seeing chargebacks...because Medicare billing isn't adjudicated in real-time. The paperwork gets done days and months later...and if the dx is not right, you get a charge back. If the 3rd party staff can't get a CMN form back from the MD, it's a charge back. If none of these things/paperwork add up when the 3rd party team goes to do the billing...you will get a chargeback and you will get a rejection on the next refill. Yes, you will take losses for a good number of these but that is the cost of doing business that Walgreens is willing to take.

Medicare B and Supplemental Insurance (Medigap)

Medicare B usually covers about 80% of the cost for patients and they're left with about 20%...this is just a rough estimate. Some patients will choose to purchase additional coverage called Medicare Suppemental Insurance or Medigap policy. This is to supplement their Medicare Part B and is used to pay the copay left over from Part B. You can scan this under "SUPPLEMENTAL/COB" in IC+ when you highlight or click on MEDICARE in 3rd party window. IC+ will allow you to scan 1 card in and use that as COB. Again, the billing is not done in real time. When you do this...it will go through for 0 and if it turns out that whatever you scanned in isn't active or correct, you will get a charge back months later.

NJMED---HZMY (HMO)

1. NJMED is straight medicaid from NJ. Molina is the administrator. Most people when they first sign up for medicaid will have NJMED because they have not been assigned an HMO yet. NJMED will require that you call Molina for a lot of meds to go through. These scripts will often reject for PA needed----but it's not a hard reject. The pharmacist can call Molina and get these overidden. Molina will ask for the last 5 digits of the ICN rejection code and the EDITs code. Most edits can be overridden by just talking to them on the phone. They are only open M-F...8A-5PM. They have pharmacists on call for emergency overrides if you need it.

2. HZMY (HMO). There are 4 Medicaid HMOs in NJ (Horizon, Aetna, United Healthcare, and Amerigroup) and most patients who initially get NJMED will eventually be assigned to one of these four plans. These companies contract with the state to help manage their benefits for New Jersey. When patients are assigned an HMO...their NJMED becomes inactive for pharmacy. You have to bill the HMO. When a patient is eligible for medicaid but also works and has commercial insurance...medicaid becomes secondary and the patient's work insurance becomes primary. You can COB HZMY after billing the patient's private insurance first. I've seen alot of techs and pharmacists that simply tell patients their HZMY is no longer billable because they have another primary and then proceed to only bill their private insurance, so a lot of times I look like an ass correcting them. Many patients have both...and you do bill both. Please do not do this to your patients...it's a great disservice to them. If you don't know...always ask.

Dual Eligible Patients (Medicare D and Medicaid)

1. Medicare D is always primary and the Medicaid HMO is always secondary. With the exception of various OTC products (vitamins), if Medicare D does not cover a drug...then the pt needs to have the MD do a PA. Medicaid will not step in to cover it.

2. For vitamins---Medicaid HMO (HZMY) will step in to pay for OTC vitamins (mainly vit Ds and aspirins) provided that they see a rejection from Medicare first. You can have the system do this automatically by having HZMY as a COB to their primariy part D plan...bill for the vitamin....get the rejection...and hit "bill secondary." After it goes through, you ahve to remember to go back and uncheck the COB box otherwise you will get all these rejections when billing for other meds. Only check the COB box for vitamins...get the claim to go through..and then go back and uncheck it.

The manual way is to bill part D first....get the rejection....leave it in TPR...and SDL it to HZMY.

FINDINS

This is just a tool to help you try to locate or pinpoint a patient's insurance. It works sometimes and most of the time it's useless. Don't fret over it. It's meant to just be an added tool to locate someone's plan as a last ditch effort towards better customer service. It's not your job to find out what insurance the patient has, and try not to make it so...otherwise you'll be on the phone all day.

I usually scan in patients Medicare card under the add card in the plan id section and never supplemental as my peers never informed me of also billing supplemental/ scanning supplemental. I have noticed however some patient may get a small $1-20 even with Medicare.. love the complaints lol. Should I be scanning in the supplemental card into ADD card part of Medicare in pt profile and wags takes care of rest or??

 

[Lnsean]

I usually scan in patients Medicare card under the add card in the plan id section and never supplemental as my peers never informed me of also billing supplemental/ scanning supplemental. I have noticed however some patient may get a small $1-20 even with Medicare.. love the complaints lol. Should I be scanning in the supplemental card into ADD card part of Medicare in pt profile and wags takes care of rest or??

YES YOU SHOULD!!! And i hate to type this in CAPS...but like 90% of my colleagues DO NOT KNOW ANYTHING about supplemental or they don't even ask. The patient is paying for supplemental coverage then you should ask them for the card and bill it so that they are getting their money's worth. Ask them if they have a "supplemental medicare insurance" or a "medigap" policy. Usually they will know what you are talking about. You can highlight the MEDICARE plan that you just inputted into 3rd party screen...at the bottom it should say "ADD SUPPLEMENTAL/COB" and then you hit "ADD CARD" and scan it in. Danville will take care of the rest. If you scan in an inactive card or a nonvalid card...it will still go through for 0...the patient will just get a bill later on for whatever small amount that was charged back from the failed supplemental insurance. They will get a letter that explains that and they can choose to pay.

 

[Lnsean]

No reject here for 3-4x testing. We just have to fax an overutilization form into the Dr, they fill it out for why they have to test more often and then we put that into their med dme file.

Sent from my VS995 using Tapatalk

Huh? I get rejections all the time...and it rejects for CMN. Danville will not let it go through unless that form is on file...so it's still being rejected until then. What state do you work in although it shouldn't matter since it's a federal program?

 

[PangoPillPusher]

Huh? I get rejections all the time...and it rejects for CMN. Danville will not let it go through unless that form is on file...so it's still being rejected until then. What state do you work in although it shouldn't matter since it's a federal program?

Sorry, I'm not from Wag, so it must be a company reject, not a Medicare reject. I'm in Ohio, but at a grocery store chain (not WM).

Sent from my VS995 using Tapatalk

 

[Lnsean]

Sorry, I'm not from Wag, so it must be a company reject, not a Medicare reject. I'm in Ohio, but at a grocery store chain (not WM).

Sent from my VS995 using Tapatalk

Yes, it's implied since Medicare billing is not done in real time that it's a company reject. Your store is probably just fronting the patients the test strips first while you're waiting for the documentations. Wags does not operate that way.

 

[pharmaking]

YES YOU SHOULD!!! And i hate to type this in CAPS...but like 90% of my colleagues DO NOT KNOW ANYTHING about supplemental or they don't even ask. The patient is paying for supplemental coverage then you should ask them for the card and bill it so that they are getting their money's worth. Ask them if they have a "supplemental medicare insurance" or a "medigap" policy. Usually they will know what you are talking about. You can highlight the MEDICARE plan that you just inputted into 3rd party screen...at the bottom it should say "ADD SUPPLEMENTAL/COB" and then you hit "ADD CARD" and scan it in. Danville will take care of the rest. If you scan in an inactive card or a nonvalid card...it will still go through for 0...the patient will just get a bill later on for whatever small amount that was charged back from the failed supplemental insurance. They will get a letter that explains that and they can choose to pay.

Yea Thanks a lot for the info, I’ve worked in SFL and now Northern VA, no colleagues superiors etc ever showed me about supplemental billing, I am aware of chargebacks and what not and the ADD CARD, but that whole $0 copay thing never really made sense although I know Medicare isn’t real time billing, I will now definitely change the way I help patients out! Always love learning new ways to help patients out.