humana pharmacy solutions
TRANSCRIPT
Audit Guide
Introduction
1.0 Overview
2.0 Types/Description of Process
2.1 Telephone
2.2 Desktop
2.3 Onsite
3.0 Appeals
4.0 Adjustments
5.0 Documentation Requirements
5.1 For an E-Script
5.2 E-Script Controlled Substances
5.3 Retail
5.4 Long-term-care (LTC) Providers
5.5 Signature Log-Elements
5.6 Retail Pharmacy Providers
5.7 Long-term-care Providers
6.0 General Pharmacy Audit Guidelines
6.1 Quantity/Days Supply
6.2 Insulin
6.3 Dispense As Written (DAW)
6.4 Ophthalmic/Otic Solutions
6.5 Ophthalmic/Otic Suspensions
6.6 Inhalers
6.7 Kits
6.8 Injections
6.9 “As Directed”/ “PRN”
6.10 Compounds
6.11 Reversals
6.12 Origin Code
6.13 Prescriber ID
6.14 Changes to Prescription
6.15 Package Sizes
6.16 Evaluation and Mitigation Strategy (REMS) Programs
6.17 Network Selection
7.0 Discrepancy List
8.0 Appendix:
8.1 Pharmacy Audit Appeal Form
8.2 Humana LTC Pharmacy Documentation Guidelines
8.3 FAQ Document
Humana Pharmacy Solutions
Introduction
Humana Pharmacy Solutions (Humana) values the services offered to Humana members by our network
of pharmacy providers. This Humana Audit Guide is provided to explain Humana‟s Pharmacy Audit
Program. It is our goal for Humana network pharmacies to understand the pharmacy audit process. In
addition, our network pharmacies are prepared to respond appropriately and to cooperate with a
Humana-initiated audit of pharmacy claims.
Humana maintains a pharmacy audit program i.) to help ensure validity and accuracy of pharmacy
claims for our clients (including the Centers for Medicare & Medicaid Services (CMS)), ii.) to help
ensure compliance with the Provider Agreement between Humana and our network pharmacies, and iii.)
to provide education to our network pharmacies regarding proper submission and documentation of
pharmacy claims.
According to the Pharmacy Provider Agreement between Humana and our network pharmacies,
Humana, any third-party auditor designated by Humana, or any government agency allowed by law, are
permitted to conduct audits of any and all books, records and prescription files related to services
rendered to members.
1. Overview
Humana (or its designee) conducts telephone, desktop and onsite audits. The results of these audits are
communicated verbally (in the case of a successfully resolved telephone audit), via mail or via electronic
mail (e-mail). Pharmacies have an opportunity, when applicable, to submit additional documentation or
“post audit” documentation to Humana for additional review. A pharmacy that disagrees with the audit
findings may dispute Humana‟s determination through the submission of the “Pharmacy Audit Appeal
Form,” which will be reviewed by the Pharmacy Audit Appeal Committee. Once appeals have been
heard and a determination has been reached by the Pharmacy Audit Appeal Committee, discrepant
claims will be addressed through the adjustment process.
The Humana pharmacy claim adjustment process addresses discrepant claims through one of the
following methods:
Correct the discrepant claim information, reflecting deduction or addition of funds
from/to the initial payment (partial recovery)
Reversal of a claim (full recovery)
Line item adjustment of a claim (reduction in payment on the pharmacy remittance)
Deductions will be made against future claim submissions and will be recorded on the pharmacy‟s
remittance statement (or 835) after all appeals on the audit findings have occurred.
Audit findings may result in a Corrective Action Plan (CAP). Failure to comply with a CAP may result
in additional audits or additional corrective actions that may include penalties up to and including
termination from Humana‟s pharmacy network.
Failure or refusal to comply with an audit request may result in a full recovery of the total amount paid
to the pharmacy for the claims involved in the audit review, including all amounts or fees paid to the
pharmacy by Humana and/or its member(s). Refusal or denial to comply with any audit type (as
described below in Section 2) may result in corrective action up to and including termination of the
pharmacy‟s Provider Agreement with Humana.
In General, the Audit Process is:
Humana
Pharmacy notified
of scheduled audit
Humana
Appeal
documentation
reviewed and audit
results finalized
Humana
Review post audit
documentation and
notify pharmacy of
final results
Humana
Notifies pharmacy
of initial audit
results
Humana
Audit reviews
documentation
Pharmacy
Submits
supporting
documentation
Pharmacy
Appeal window to
submit appeal
form
Pharmacy
Post audit window
to submit rebuttal
documentation
Humana
Claims adjustment
process
Audit complete
2. Audit Types/Description of Process
Humana currently utilizes the following types of pharmacy audit:
2.1 Telephone
In some cases, the pharmacy may be contacted via phone to verify claim(s) submission and request the
pharmacy to correct claim billing, if necessary. This type of audit will only be done on a small number
of claims; any large group of claims will be reviewed through desktop or onsite processes. Failure to
comply with a telephone audit will result in either a desktop or an onsite audit.
2.2 Desktop
Claims selected for desktop audit are grouped together and audited concurrently. The pharmacy will
receive, via established communication method (most often letter), a communication requesting claim(s)
documentation from the pharmacy that will include a specific deadline (typically 30 calendar days), the
claim(s) being audited, required documentation, and auditor contact information. The pharmacy must
submit requested documentation for all indicated claims back to Humana to substantiate and validate
claims previously received. Failure to respond to an audit by the initial due date (unless an extension is
granted prior to the due date) will result in assessment of a penalty according to the following chart:
If documentation is received: Penalty assessed will be:
Prior to the audit deadline None
After the audit deadline but before the
post audit deadline
25 percent of the total value of the audited
claims
After the post audit deadline 100 percent of the total value of the
audited claims
The pharmacy may submit documentation to Humana via mail or e-mail. Humana will review
documentation submitted by the pharmacy to validate accuracy of the documentation for the claim
previously submitted, and for compliance with all laws, rules, regulations, Humana benefit limits or
other requirements as outlined in the Pharmacy Provider Manual and Pharmacy Provider Agreement.
Upon review of all documentation, an initial audit result letter will be sent to the pharmacy.
The pharmacy will be allowed approximately 30 calendar days from the date of the initial audit result
letter to supply additional documentation to mitigate discrepant claims (see Humana Discrepancy List
for acceptable documentation, in Appendix 6.1). Humana will review any additional documentation
received by the deadline and determine if any previous discrepancies can be removed. Upon review of
any and all documentation received prior to the deadline, a final audit result letter will be sent to the
pharmacy.
The pharmacy will be allowed approximately 15 calendar days from the date of the final audit result
letter (specified in the final audit result letter) to further dispute by submitting an appeal. All appeals
must be properly submitted on an appeal form, as outlined in section 3.0.
2.3 Onsite
A pharmacy selected for an onsite audit will receive a notification letter via mail, which specifies the
date of the audit, date range of claims being audited and auditor contact information. The auditor will
follow up with the pharmacy approximately seven calendar days prior to the audit to supply additional
information for the pharmacy to prepare for the audit and to answer any questions. Failure to comply
with an onsite audit may result in a penalty equal to the total value of the audited claims, as well as a
corrective action up to and including termination from Humana‟s pharmacy network.
An onsite audit will be conducted at the pharmacy‟s physical location. The auditor will review
documentation including, but not limited to, hard copy prescription documentation, signature logs,
documentation logs (if any) and compliance with the Pharmacy Provider Agreement. Humana requires
the auditor be provided a clean work space, away from the dispensing area (as to not disrupt pharmacy
practice), and assistance in locating requested audit documentation. All documentation must be pulled
within eye sight of the auditor, if possible, or the auditor reserves the right not to accept the
documentation. An onsite audit will generally involve more claims than a telephone or desktop audit.
The onsite auditor will also review pharmacy procedures, compliance with specific sections of the
Provider Agreement, and any applicable rules, laws and regulations. Upon review of all documentation,
an initial audit result letter will be sent to the pharmacy, typically within seven to 10 business days of the
onsite audit.
The pharmacy will be allowed approximately 30 calendar days from the date of the initial audit result
letter to supply allowable additional documentation to mitigate discrepant claims (see Humana
Discrepancy List for acceptable documentation, located in Appendix 6.1). The auditor will review
additional documentation received by the deadline and determine if any previous discrepancies can be
removed. Upon review of any and all documentation received prior to the deadline, a final audit result
letter will be sent to the pharmacy.
The pharmacy will be allowed approximately 15 days from the date of the final audit result letter
(specified in the final audit result letter) to further dispute by submitting an appeal. All appeals must be
properly submitted on an appeal form, as outlined in section 3.0.
3.0 Appeals
All pharmacies are provided an opportunity to respond to audit findings by filing a written appeal on the
“Pharmacy Audit Appeal Form” (see Pharmacy Audit Appeal Form, in Appendix 8.1) within 15 days
from the date of the final audit result letter. The intent of the appeal is to allow pharmacies the
opportunity to provide a written explanation describing why the pharmacy disagrees with the audit
findings for each claim deemed discrepant. It is not expected that pharmacies will produce additional
prescription documentation during an appeal, as it is expected that the pharmacy would have submitted
all applicable documentation prior to an appeal. Appeals should be submitted via certified United States
Postal Service®, FedEx
®, UPS
® or other certified carrier. The Humana Pharmacy Appeal Committee
will not, as a matter of policy, review appeals or disputes not submitted on the Humana Pharmacy Audit
Appeal Form. Upon review of an appeal, an appeal results letter will be sent to the pharmacy, detailing
the decision of the Humana Pharmacy Appeal Committee.
4.0 Adjustment
Any calculations represented on any initial or final audit reports are estimated or proposed recoveries.
Actual recovery amounts are not known until the claim adjustments occur and are communicated
through the pharmacy‟s remittance advice statement.
Humana will offset amounts due to Humana due to audits from subsequent pharmacy payments until the
audit recoveries have been collected in full. In the event Humana is unable to offset from future
payments, the pharmacy must pay Humana the amount owed within 30 calendar days of written notice
from Humana.
5.0 Documentation Requirements
In general, for a hard copy prescription or electronic prescription, the front and back of the hard copy or
electronic prescription documentation must be submitted. The following are elements of the prescription
that must be included on the documentation (unless contradicted by state law) for the documentation to
be considered acceptable:
Name of the patient
Date of prescription issuance
Name, strength and dosage form (if applicable) of the drug prescribed
Directions for use (or the maximum daily dosage allowed by the prescriber)
Quantity prescribed
Number of refills (or a clear start and stop date or for cycle fills a continue until told
to discontinue date)
National Provider Identifier (NPI) of the prescriber (or at minimum the name of the
prescriber for nonscheduled medications)
Prescriber‟s Drug Enforcement Agency (DEA) registration number (for scheduled
medications)
Prescriber‟s signature (or in the case of a phone-in prescription order the full name of
the individual from whom the pharmacist received the prescription order)
The unique prescription identifier (prescription number)
5.1 Documentation Requirements for an Electronic Prescription
According to the Pharmacy Provider Agreement, pharmacies must be able to accept electronically
submitted prescriptions from prescribers in National Council for Prescription Drug Programs (NCPDP)
Version 8.1 (Prescriber/Pharmacist Interface SCRIPT Standard, Implementation Guide) or most current
NCPDP format. Pharmacies are required to populate NCPDP field 419-DJ with the prescription origin
code of three for all prescriptions submitted to a provider using an ePrescribing method for claims
submitted to Humana‟s claims processor/administrator.
5.2 Documentation Requirements Electronic Prescriptions for Scheduled Medications
Pharmacy systems must comply with Drug Enforcement Agency (DEA) guidance related to
requirements for electronic prescribing of controlled substances. Pharmacy systems that accept
electronically prescribed prescriptions for scheduled medications must retain digital signatures received.
Pharmacies must also validate the DEA registration of a prescriber from whom an electronic
prescription has been received when there is some reason to suspect a lack of validity.
5.3 Documentation Requirements for Retail Pharmacy Providers
There are no additional requirements related to hard copy prescription documentation, unless otherwise
required by law.
5.4 Documentation Requirements for Long-term-care Providers
Humana recognizes the elements of a prescription may not be found on one hard copy prescription, but
requires a combination of the “Chart Order” and the “Prescription Drug Order” to constitute a full hard
copy prescription. Please see Appendix 8.2 for long-term-care guidelines.
5.5 Signature Log Elements
Humana requires, at minimum, the following data elements on all signature logs:
Full Patient Name
Date of Fill
Rx Number
Signature of the Member (or legal representative)
Date of Pick Up or Delivery
5.6 Signature Log Elements for Retail Pharmacy Providers
All of the elements listed above must be present on a signature log, unless required by law.
5.7 Signature Log Elements for Long-term-care Providers
Humana recognizes that, generally, long-term-care pharmacies do not collect signature logs as is the
standard for retail pharmacy providers. If a signature log is provided by a long-term-care pharmacy and
meets the requirements of a retail pharmacy provider, Humana will accept it as a signature log for a
long-term-care provider. However, if a signature log is not available, Humana requires a delivery
manifest or other documentation that clearly displays the member received the medication. Please see
Appendix 8.2 for long-term-care guidelines.
5.8 Additional Documentation
Humana has the right to request additional documentation for auditing purposes, which includes, but is
not limited to, the following:
Purchase Invoices and Reports
Credentialing Documentation
Contract Compliance Documentation
Compliance with Medicare Rules and Regulations
Training Documentation
Employee Documentation
6.0 General Pharmacy Audit Guidelines
6.1 Quantity/Days Supply The quantity prescribed by the physician should be dispensed and submitted to Humana in
conjunction with the correct days supply. If Humana rejects the claim, due to quantity or days
supply limits, the claim should be readjudicated with a quantity and days supply consistent with the
directions for use and the plan‟s specific limitations. For eye drops, inhalers and topical agents, if
the prescription is written for a quantity of one, the pharmacy should dispense the smallest
commercially available product. If a larger package size is dispensed, an appropriate reason should
be documented either on the hard copy prescription or within another readily retrievable system and
should be provided during an audit.
6.2 Insulin Claims should be submitted for the correct quantity and days supply based upon the number of units
per day. As it is typical for insulin doses to vary, a maximum daily dose should be used to calculate
the quantity and days supply. The maximum daily dose should always be documented on the hard
copy prescription and should be provided during an audit.
6.3 Dispense As Written (DAW)
Humana recognizes the NCPDP codes for dispense as written situations. For any prescription submitted
with a DAW code other than zero, the reason for the selected code must be documented and must be in
compliance with all applicable laws, rules and regulations.
6.4 Ophthalmic/Otic Solutions Unless otherwise indicated by the manufacturer, Humana calculates solutions as having 20 drops
per milliliter (mL). All claims should be submitted based upon the 20 drops per mL guideline and
adjusted to the proper quantity and days supply accordingly.
6.5 Ophthalmic/Otic Suspensions Unless otherwise indicated by the manufacturer, Humana calculates suspensions as having 15 drops per
milliliter (mL). All claims should be submitted based upon the 15 drops per mL guideline and adjusted
to the proper quantity and days supply accordingly.
6.6 Inhalers In most cases, inhalers should be submitted according to the metric decimal quantity as indicated by the
manufacturer and not by the number of inhalations for the given inhaler.
6.7 Kits In most cases, kits should be billed by the number of kit(s) dispensed at the time of fill, not the
number of units found within the kit. If the number of kit(s) is not applicable, reference the First
Data Bank (http://www.firstdatabank.com).
6.8 Injections
In general, injections should be billed by the number of mL being dispensed, not the number of
injections or bottles dispensed. If the number of mL is not applicable, reference the First Data Bank
(http://www.firstdatabank.com).
6.9 “As Directed”/ “PRN”
With the exception of dosage packs, Humana prohibits the use of “As Directed.” For drugs that may
fluctuate dosage, a maximum or “up to” daily dose should be used to calculate the appropriate days
supply and documented on the hard copy prescription. For topical agents, the affected area should be
documented on the hard copy prescription or another readily retrievable system, unless dispensing the
smallest commercially available package.
6.10 Compounds The cost of the compound should not exceed the contract rate of the covered ingredients used. Upon
audit, Humana will require a compound worksheet be submitted for each compound, which
includes the NDC, quantity and cost of each ingredient.
6.11 Reversals Humana requires any claims not picked up within 15 business days to be reversed.
6.12 Origin Code For a new prescription, a valid Prescription Origin Code (POC) must be submitted beginning
January 1, 2010. Humana requires this field to be populated correctly for all claims, Medicare and
commercial. POC is to be populated with the approved valid values below:
1 = Written
2 = Telephone
3 = Electronic
4 = Facsimile
6.13 Prescriber ID Humana requires the correct National Provider Identifier (NPI) be submitted for each claim. When
an NPI is not available or cannot be obtained, the appropriate Drug Enforcement Agency (DEA)
registration number may be used. Submission of an incorrect, invalid or “dummy” prescriber
identifier will result in a claim being considered discrepant.
6.14 Changes to Prescriptions Any change in an element of a prescription, as defined in section 5.0 (Documentation
Requirements), must be documented and submitted along with all other documentation related to
the hard copy prescription.
6.15 Package Sizes The package size dispensed must be the proper package size based upon the directions of the
prescription. If the proper package size is not in stock, Humana expects (unless in an emergency)
either the smaller package size will be dispensed or the proper package size will be ordered for
dispensing within 24 hours.
6.16 Risk Evaluation and Mitigation Strategy (REMS) Programs
Medications with special and specific Food and Drug Administration (FDA) guidelines must be
dispensed in accordance with the guidelines.
6.17 Network Selection All claims must be submitted to the appropriate network and reimbursed based upon the rate for the
network. To ensure the correct network is selected, ensure the days supply is correctly calculated
and the patient location code and level of service fields are entered appropriately.
7.0 Discrepancy List
The Discrepancy Code List defines each type of potential discrepancy identified during an audit. In
addition, this list should be used to respond to the audit findings. Finally, it provides justification for the
type of charge back occurring upon finalization of the audit.
Humana requires the following elements to consider a prescriber statement valid for post-audit
documentation:
The address and telephone number of the prescriber should be printed on the
prescriber‟s own letterhead
Member name, medication(s), date(s) of service, strength, directions, quantity ordered
and refills (if applicable) should be included within the document
The original method and date of the prescription should be included within the
document
The document should include the prescriber‟s signature
Note: “Call in” or “Phone in” prescriptions are not acceptable during the post audit phase.
Humana requires the following elements to consider a member statement valid for post-audit
documentation:
Member address and telephone number
Medication(s), Rx number(s) and date(s) of service
Member signature
BMN – Dispense as Written
Definition:
Brand medication billed, but member or prescriber‟s “brand-only” order is not
documented. Prescriber must specify "Dispense as Written" on hard copy or
pharmacy must document prescriber request or, when required by state
regulations, member request for brand name dispensing.
Acceptable Post
Audit
Documentation:
DAW 1 – Prescriber Statement, which validates that the substitution of
generic product was authorized.
DAW 2 – Member Statement, which validates that the substitution of
generic product was authorized.
DAW 7 – Legal reference, which mandates that a specific product be
dispensed by brand name only.
Discrepancy
Result:
Partial charge back due to pharmacy submitting incorrect DAW code. Claim will
be corrected in the amount of the difference between the brand and generic
contracted rate.
CPDF – Compound Incorrectly Billed
Definition: A compounded prescription is incorrectly billed resulting in an overpayment.
Acceptable Post
Audit
Documentation:
Compound worksheet with ingredients listed National Drug Code (NDC) and
Quantity.
Discrepancy
Result:
Full charge back due to compound being billed with noncovered Part D drugs, an
incorrect compound indicator or other indicators that lead to inappropriate
payment.
CPDP – Compound Incorrectly Billed
Definition: A compounded prescription is incorrectly billed resulting in an overpayment.
Acceptable Post
Audit
Documentation:
Compound worksheet with ingredients listed (NDC and Quantity).
Discrepancy
Result:
Repriced with compound worksheet. The overpriced amount will be recovered
based upon the pricing available in the compound worksheet.
CPDW – Compound Worksheet Required
Definition: Prescription is submitted using an inappropriate compound indicator or incorrect
NDC #.
Acceptable Post
Audit
Documentation:
Compound worksheet required.
Discrepancy
Result:
Full charge back due to missing compound worksheet to validate the claim.
DDB – Different Drug Billed
Definition:
Pharmacy billed for a different medication than the one ordered by the prescriber
with no documentation on prescription or member profile.
Acceptable Post
Audit
Documentation:
For therapeutic exchange, prescriber statement will be accepted in post
audit to verify change was authorized in prescribed product.
All other discrepancies not due to therapeutic exchange, no post audit
documentation will be accepted.
Discrepancy
Result:
Full charge back due to pharmacy submitting claim for different product than
prescribed. Documentation should be available at the time of audit.
DEA – No DEA
Definition: The hard copy prescription does not contain a DEA number (CII-CV drugs only).
Acceptable Post
Audit
Documentation:
No post-audit documentation will be accepted.
Discrepancy
Result:
Full charge back because this element is required by law for a controlled substance
prescription to be valid. Post-audit documentation will not be accepted because
according to federal regulations, the prescriber DEA should be on the prescription
hard copy prior to dispensing. If a controlled substance prescription does not
contain the prescriber's DEA, the prescription should not be filled until the
prescriber's DEA can be obtained and documented.
DID – Wrong Prescriber
Definition: Incorrect prescriber billed or inappropriate use of prescriber ID.
Acceptable Post
Audit
Documentation:
Prescriber statement from a nonsanctioned prescriber that shows the
prescriber billed is a member of the same practice as the correct prescriber
or proof that a reasonable effort was made to bill the correct prescriber ID.
CII-CV, no post-audit documentation will be accepted.
Discrepancy
Result:
Full charge back due to pharmacy submitting claim with an incorrect prescriber ID
or with a sanctioned prescriber ID. A prescriber statement from a nonsanctioned
prescriber will be accepted as post-audit documentation to verify the submitted
prescriber is from the same practice as the correct prescriber. No post-audit
documentation will be allowed for controlled substance prescriptions.
DN-1 – Wrong Member Billed
Definition:
The member identified on a hard-copy prescription is not the member identified on
the paid claim.
Acceptable Post
Audit
Documentation:
Member statement or member identification
Discrepancy
Result:
Full charge back due to claim billed to wrong member. A member statement will
be accepted during post audit to clarify the member‟s identification.
DUP – Duplicate Claim
Definition: Multiple claims for the same prescription fill were paid. A duplicate claim is
defined as the same member, product, dosage and close approximate fill dates.
Acceptable Post
Audit
Documentation:
No post-audit documentation will be accepted.
Discrepancy
Result:
Full charge back due to duplicate claim. Humana's expectation is that pharmacies
will obtain appropriate authorization to fill scripts early rather than circumventing
system edits. No post-audit documentation will be accepted because this situation
could lead to a potential patient safety risk.
EQB – Exceeds QTY Limits/Overfilled QTY
Definition:
Quantity billed exceeds the quantity authorized by the prescriber or plan. The
pharmacy submitted a quantity greater than the quantity prescribed or a quantity
that would last greater than the days supply limit of the plan.
Acceptable Post
Audit
Documentation:
No post-audit documentation will be accepted.
Discrepancy
Result:
Partial charge back will reflect the difference between the original paid amount
and the corrected paid amount. No post-audit documentation will be allowed for
excessive quantity.
EXP – Exceeds Time Limit
Definition:
The prescription is filled or refilled for a time period longer than allowed by the
plan or applicable law.
Acceptable Post
Audit
Documentation:
An updated copy of the state code or federal regulation defining the valid length of
time that prescriptions of the control level in question may be filled.
Discrepancy
Result:
Full charge back of discrepant claim submissions due to the prescription expiring
prior to being dispensed. Updated legal information allowed for post-audit
documentation, if pharmacy can provide legal reference that can be validated as
more current or different from what was cited in audit.
FBW – Filled before Written
Definition: Prescription was filled before date written.
Acceptable Post
Audit
Documentation:
Prescriber statement that validates the prescriber indicated the incorrect date.
Discrepancy
Result:
Full charge back due to claim being billed before script was written. Prescriptions
should not be filled before the original date written without authorization from the
prescriber.
FTR – Failure to Respond
Definition: Pharmacy fails to respond to audit.
Acceptable Post
Audit
Documentation:
Tracking evidence indicating that the pharmacy attempted to mail the audit
documentation within the audit window.
Discrepancy
Result:
Full charge back due to pharmacy not responding to desktop audit. Tracking
information showing proof of delivery or attempt to ship package.
ICS – Wrong Pack Size
Definition:
The package size submitted on the claim differs from the package size dispensed
by the pharmacy or if the pharmacy bills multiples of a smaller size NDC when a
stock larger size is available resulting in excess margins.
Acceptable Post
Audit
Documentation:
Documentation from wholesaler that shows supply issues occurred at the time of
fill with the larger package size.
Discrepancy
Result:
Full charge back due to pharmacy submitting claim for different product than
prescribed (acceptable substitution an exception) or claim submitted for incorrect
package size. Prescriber statement allowed for post audit to verify change in
prescribed product or wholesaler documentation verifying that the specific
package size in question was not in stock or unavailable at the time of fill.
IDS – Wrong or Incorrect Day Supply
Definition:
The days supply value submitted by the pharmacy is not consistent with the
quantity and directions.
Acceptable Post
Audit
Documentation:
No post-audit documentation will be accepted.
Discrepancy
Result:
Partial charge back due to pharmacy submitted incorrect day supply calculation
per prescribed directions. No post-audit documentation allowed because submitted
day supply does not match the hard copy's prescribed directions.
INV – No Date Written
Definition: Hard copy prescription contains no written date, as required by law.
Acceptable Post
Audit
Documentation:
Prescriber statement (CII-CV, no post-audit documentation will be accepted.)
Discrepancy
Result:
Full charge back because this element is required by law for a prescription to be
valid. Prescriber statement will be allowed for post-audit documentation to verify
that submitted information is correct.
INVP – No Doctor Name
Definition:
The hard copy prescription does not identify the Prescriber by signature, as
required by law.
Acceptable Post
Audit
Documentation:
Prescriber statement (CII-CV, no post-audit documentation will be accepted.)
Discrepancy
Result:
Full charge back because this element is required by law for a prescription to be
valid. Prescriber statement will be allowed for post-audit documentation to verify
that submitted information is correct.
INVD – No Drug Name
Definition:
The hard-copy prescription does not contain the name of the drug to be dispensed,
as required by law.
Acceptable Post
Audit
Documentation:
Prescriber statement (CII-CV, no post-audit documentation will be accepted.)
Discrepancy
Result:
Full charge back because this element is required by law for a prescription to be
valid. Prescriber statement will be allowed for post-audit documentation to verify
that submitted information is correct.
INVN – No Member Name
Definition: The hard-copy prescription contains no member name, as required by law.
Acceptable Post
Audit
Documentation:
Prescriber statement (CII-CV, no post-audit documentation will be accepted.)
Discrepancy
Result:
Full charge back because this element is required by law for a prescription to be
valid. Prescriber statement will be allowed for post-audit documentation to verify
that submitted information is correct.
INVS – No Strength
Definition:
The hard-copy prescription, for a drug available in more than one strength, fails to
identify the strength to be dispensed, as required by law.
Acceptable Post
Audit
Documentation:
Prescriber statement (CII-CV, no post-audit documentation will be accepted.)
Discrepancy
Result:
Full charge back because this element is required by law for a prescription to be
valid. Prescriber statement will be allowed for post-audit documentation to verify
that submitted information is correct.
IOC – Incorrect Origin Code
Definition: The origin code submitted for the claim differs from the hard-copy prescription.
Acceptable Post
Audit
Documentation:
No post-audit documentation will be accepted.
Discrepancy
Result:
This element is used during a desktop audit to ensure that submitted
documentation is accurate as referenced in Humana's provider contract. CMS has
also provided guidance stressing the accuracy of this field for correct Prescription
Drug Event (PDE) submissions. Full charge back due to pharmacy submitting
claim with an incorrect origin code. Post-audit documentation will not be allowed
because there is no reasonable documentation available to remove the discrepancy
due to the requirement to submit the correct origin code at the time of fill.
LAWF – Law Not Followed
Definition: Prescription not filled in accordance with state/federal law.
Acceptable Post
Audit
Documentation:
An updated copy of the state code or federal regulation with reference code
number.
Discrepancy
Result:
Full charge back due to pharmacy not operating in observance of federal or state
regulations. Updated law information allowed for post-audit documentation if
pharmacy can provide legal reference that can be validated as more current or
different from what was cited in the audit.
LAWP – Law Not Followed
Definition: Prescription not filled in accordance with State/Federal law.
Acceptable Post
Audit
Documentation:
An updated copy of the state code or federal regulation with reference code
number.
Discrepancy
Result:
Partial charge back due to pharmacy not operating in observance of federal or state
regulations. Updated law information allowed for post audit if pharmacy can
provide legal reference that can be validated as more current or different from
what was cited in audit.
MP-1 – Missing Prescription
Definition: Original hard-copy prescription cannot be found on file during the audit.
Acceptable Post
Audit
Documentation:
Prescriber statement.
Discrepancy
Result:
Full charge back due to pharmacy not providing prescription authorization record.
Prescriber statement allowed for post-audit documentation to verify that
prescription was written by prescriber for specific member and listed date.
MSLD – Not Dispensed
Definition:
Prescription is billed, but not dispensed to member. Drugs are not returned to
stock. Partial fills not picked up and not reversed.
Acceptable Post
Audit
Documentation:
Member statement.
Discrepancy
Result:
Full charge back due to prescription not being picked up or delivered. Member
statement allowed for post-audit documentation to confirm receipt of prescription.
MSL – Signature Not Found
Definition:
The signature documenting receipt of pharmacy services cannot be found in the
signature logs.
Acceptable Post
Audit
Documentation:
Member statement.
Discrepancy
Results
Full charge back due to prescription not being picked up or delivered. Member
statement allowed for post-audit documentation to confirm receipt of prescription.
NORX – No Rx Number
Definition: The hard copy prescription contains no unique prescription identifier number.
Acceptable Post
Audit
Documentation:
A computer generated label/sticker with all defined prescription elements.
Discrepancy
Result:
Full charge back because this element is required by law for a prescription to be
valid. Computer-generated label will be allowed for post-audit documentation to
verify that submitted information is correct.
NQY – No Quantity
Definition: Prescription quantity is not complete; no quantity on prescription.
Acceptable Post
Audit
Documentation:
Prescriber statement.
Discrepancy
Result:
Full charge back because this element is required by law for a prescription to be
valid. Prescriber statement will be allowed for post-audit documentation to verify
that submitted information is correct.
NSI – No Directions For Use or Use as Directed
Definition: Prescription lacks specific, calculable directions (use as directed or missing
directions).
Acceptable Post
Audit
Documentation:
Prescriber statement (must include exact directions or a maximum daily dose).
Discrepancy
Result:
Full charge back because this element is required by law for a prescription to be
valid. Also required for accurate dosage and day supply calculation. Prescriber
statement will be allowed for post-audit documentation to verify that submitted
information is correct.
OTHF – Miscellaneous Discrepancy
Definition:
„OTHER‟ is assessed when an issue has been cited that is not listed elsewhere on
the discrepancy list. Detailed explanation will be given when this discrepancy is
cited.
Acceptable Post
Audit
Documentation:
Depends upon discrepancy. Detailed explanation will be given when this
discrepancy is cited.
Discrepancy
Result:
Full charge back due to any other reason not listed elsewhere on the Humana
Pharmacy Solutions Audit Discrepancy Code List. This discrepancy will be cited
when circumstance requires claim correction and education to pharmacy. Post-
audit documentation will be allowed or not allowed depending on discrepancy and
circumstance.
OTHP – Miscellaneous Discrepancy
Definition:
„OTHER‟ is assessed when an issue has been cited that is not listed elsewhere on
the discrepancy list. Detailed explanation will be given when this discrepancy is
cited.
Acceptable Post
Audit
Documentation:
Depends upon discrepancy. Detailed explanation will be given when this
discrepancy is cited.
Discrepancy
Result:
Partial charge back due to any other reason not listed elsewhere on the Humana
Pharmacy Solutions Audit Discrepancy Code List. This discrepancy will be cited
when circumstance requires claim correction and education to pharmacy. Post-
audit documentation will be allowed or not allowed depending on discrepancy and
circumstance.
RXC – Altered Prescription
Definition: Prescription altered without appropriate documentation.
Acceptable Post
Audit
Documentation:
Prescriber statement validating changes were authorized and appropriate.
Discrepancy
Result:
Full charge back due to unauthorized or improperly documented alterations to
prescription hard copy. A prescriber statement will be allowed for post-audit
documentation to confirm or validate that changes were authorized and
appropriate.
RXCQ – Cut Quantity
Definition:
A quantity less than that prescribed is billed and additional refills are dispensed
resulting in undue dispensing fees.
Acceptable Post
Audit
Documentation:
Member statement that indicates a request for change.
Discrepancy
Result:
Partial charge back in the amount of the dispensing fee due to the pharmacy
submitting incorrect quantity by submitting a quantity greater than the face value
of the RX or by cutting the quantity to less than prescribed. No post-audit
documentation will be allowed for excessive quantity. A member statement will be
allowed for post-audit documentation on cut quantity. Member statement will be
used to confirm his/her request to receive less than prescribed.
UAR – Unauthorized Refill
Definition: Prescription is refilled more times than prescribed.
Acceptable Post
Audit
Documentation:
Prescriber statement validating prescriber's authorizing refills prior to refill being
submitted.
Discrepancy
Result:
Full charge back for any claims submitted for unauthorized refills due to number
of authorized refills exceeded or incorrect calculation of quantity or day supply.
Prolonged duration of therapy could lead to a potential patient safety risk.
Prescriber statement will be allowed for post-audit documentation, validating
prescriber authorized additional refills prior to refill being filled.
UAR2 – Refill Too Soon
Definition:
Prescription is refilled sooner/more frequently than appropriate with respect to
quantity and directions for use.
Acceptable Post
Audit
Documentation:
No post-audit documentation will be accepted.
Discrepancy
Result:
Full charge back due to duplicate claim (same member, product, dosage and close
approximate fill dates) or refill too soon (that misses Refill Too Soon (RTS) logic
due to incorrect submitted day supply). Humana's expectation is that pharmacies
will obtain appropriate authorization to fill scripts early rather than circumventing
system edits. This situation could lead to a potential patient safety risk. Post-audit
documentation will not be allowed because there is no reasonable documentation
available to remove the discrepancy as a previous claim was submitted incorrectly
that allowed this claim to pay.
8.0 Appendix
8.1 Pharmacy Audit Appeal Form
PHARMACY AUDIT APPEAL FORM
INSTRUCTIONS
Audited pharmacies have the right to appeal the findings of an audit. The intent of the appeal
process is to allow pharmacies the opportunity to provide a written explanation for each
prescription marked discrepant. Pharmacy audit appeals are heard by the Humana Appeal
Committee. The appeal committee conducts its review based on the original audit
documentation submitted and the appeal explanation provided by the pharmacy for the
claim(s) in question. Pharmacies should utilize the Pharmacy Audit Appeal Form to provide
an explanation as to why they disagree with Humana Pharmacy Solutions‟ audit findings for
each prescription deemed discrepant.
In order for an appeal to be reviewed by the Humana Appeal Committee, all of the
information requested in the attached Pharmacy Audit Appeal Form must be provided for
each disputed prescription prior to the appeal deadline. Only claims submitted on a properly
completed Pharmacy Audit Appeal Form will be reviewed by the Humana Appeal Committee.
Appealing pharmacies may only provide information and documentation different from what
was originally submitted for the audit. The pharmacy may include additional sheets or attach a
type written explanation to the Pharmacy Audit Appeal Form, if needed.
If you have any questions about your appeal or the appeal process, please call 502-580-3232
or e-mail [email protected].
Upon Humana Appeal Committee review, you will be notified of the appeal decision.
[Form number must go here]
PHARMACY AUDIT APPEAL FORM
Pharmacy
Name:_______________________________________________________________
NCPDP/NPI #: _____________________________ Audit Date:
___________________
Pharmacy Contact Name: ______________ Contact Phone Number:
_____________________
Prescription Number:
___________________________________________________________
Date(s) of Service:
_____________________________________________________________
Humana Audit Discrepancy Code: _____________________________________________
Reason for Appeal:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________
Attachment Included: Yes / No
FOR HUMANA PHARMACY SOLUTIONS INTERNAL USE ONLY
DATE RECEIVED: ____________________________________
APPEAL MEETING DATE: ____________________________________
8.2 Humana LTC Pharmacy Documentation Guidelines
Source: National Association of Boards of Pharmacy and American Society of Consultant Pharmacist
(NABP/ASCP) Joint Report: Model Rules for Long-term-care (LTC) Pharmacy Practice, which is a
guideline of how NABP and ASCP believe LTC pharmacies should be operating.
LTC pharmacy audits may require auditors to look at multiple pieces of documentation to determine
whether the billed claim is appropriate.
For a hard copy prescription – the following are elements of the prescription that must be included on
the documentation to be considered acceptable: name of the member, date of issuance, name, strength,
and dosage form of the drug prescribed (if applicable), directions for use, quantity prescribed, number of
refills (or a clear start and stop date or for cycle fills a continue until told to discontinue date), DEA or
NPI of the prescriber or name of the prescriber for noncontrolled prescriptions, and the prescriber‟s
signature.
Acceptable Forms of Documentation:
1. Either the combination of the "Prescription Drug Order," AND the "Chart Order" or either of
the above elements found by itself
2. A hard copy prescription from a prescriber as defined by state law
3. A telephone prescription with all appropriate information as defined by state law
4. A properly documented E-script
5. Fax request for refills, as long as it contains all appropriate information (as found on a retail
audit) and is clear it came from and was approved by a prescriber
6. Discharge orders with a clear start and stop date
7. Progress notes – may accept prescriber order written in progress notes if prescriber notes
contain all appropriate prescription elements
8. Any other documentation or combination of documentation that displays all prescription
elements and demonstrates clearly that the documentation originated from a prescriber
The following will NOT be accepted as a hard copy prescription:
1. Medication Administration Records (MARs) or copies of MARs
2. LTC nurse call-in notes for controlled substances
3. Labels, which do not contain required prescription information
4. Progress notes (unless they contain all prescription information)
5. Screen prints (unless for an E-script)
6. Refill sticker alone
For Signature Logs ANY of the following should be accepted:
For signature logs, the following are elements of the log that must be included on the documentation to
be considered acceptable: If a patient picks up the medication at the facility – patient name, RX
number(s), date of service, signature of who received the medication and date received. If delivered to a
facility – patient name, date of service, RX number(s), date of service, facility delivered, date of delivery
and name of person who received medication.
1. A signature log with all required elements
2. A delivery manifest, with all elements, or a delivery manifest on which the prescriptions
delivered can be traced back to the order number
3. A copy of an MAR, which shows the prescription was administered and the name and
signature of the person who administered the mediation, the date and time the medication
was administered
4. Dated and signed statement from nurse or staff member with appropriate information as
listed above
The following will NOT be accepted for a signature/delivery log:
1. Patient receipt without patient signature
2. Compound worksheet
3. Any documentation that does not clearly display what was delivered, who delivered the
medication, where it was delivered and the date of the delivery.
Cycle Fills:
As per the Humana Pharmacy Provider Manual:
LTC pharmacies that provide medications in a cycle fill type of system may bill through the
point-of-sale system on a cycle basis, as long as the cycle doesn‟t interfere with the normal
day supply and quantity limit (QL) edits. This may be done at the first of the month or at the
end of the month, as long as the time interval in between billing cycles is consistent.
In addition, cycle fills may be utilized for maintenance medications only. For cycle fills, documentation
must clearly state the prescriber intended and authorized for the member to continue the medication.
Documentation Submission:
For chain pharmacies, documentation should be sent per your chain requirements. For independents, all
documentation should be sent to Humana Pharmacy Solutions at the following address:
Attention: Pharmacy Audit – WFP 6W
325 W Main Street
Louisville, KY 40202
8.3 FAQ Document
Audit Frequently Asked Questions (FAQ)
1. Q: Why is my pharmacy being audited and how can I prevent future audits?
A: All claims are reviewed by multiple audit factors on a daily basis. Claims are selected
randomly for audit through the use of these factors.
2. Q: For a telephone audit, can I correct the claim(s) being audited?
A: Yes. If a telephone audit occurs, pharmacies are encouraged to reverse and correctly
reprocess the discrepant claims at the time of the audit.
3. Q: For a desktop or onsite audit, can I correct the claims being audited?
A: No. The pharmacy should not attempt to adjust or correct these claims on its own. Humana
will handle any adjustments to audited claims based on the final outcome of the audit.
4. Q: How will I be notified of a desktop or onsite audit?
A: Depending on your pharmacy‟s preference, either through e-mail or mail (UPS or certified
mail.)
5. Q: What should my pharmacy submit for a desktop audit?
A: As per section 3.2 of this audit guide, an original hard copy prescription (front and back), a
copy of the signature log or delivery manifest, and a compound worksheet if applicable. Also,
please provide the requested copy of the computer-generated hard copy label, and if applicable, a
copy of the administration record(s) for vaccines.
6. Q: If a compound prescription is in question, what should I submit?
A: In addition to the hard copy documentation, a compound worksheet including the NDC of
each ingredient, the cost of each ingredient and the quantity of each ingredient used in the
compound.
7. Q: How are compound prescriptions calculated?
A: Based upon the compound worksheet, the quantity and contract rate for each ingredient is
added together.
8. Q: Who should I send my documentation to for an audit?
A: To the pharmacy audit general account e-mail address, mailing address, etc. All
documentation should be submitted on unstapled, 8 ½ x 11 inch paper.
9. Q: What can my pharmacy do to prepare for an onsite audit?
A: The pharmacy should have all documentation from the previous 18-24 months readily
retrievable. In addition, Humana‟s onsite vendor will supply a range of prescriptions two to
three days prior to the audit. The prescription books associated with these prescriptions should be
in numerical order and readily retrievable prior to the audit.
10. Q: Can my pharmacy be provided an exact list of prescriptions prior to an onsite audit?
A: No. To ensure the integrity of the audit, Humana‟s onsite vendor will not supply a list of
exact prescriptions until the date of the audit.
11. Q: Should I have a staff member assist during the onsite audit?
A: Yes. It is preferred that a staff member assist with the audit to ensure all documentation is
given to the auditor at the time of the audit.
12. Q: How can the audit deadline be extended?
A: It is expected that all documentation be submitted by the due date. However, Humana reviews
requests for extensions as requested by the pharmacy. If a pharmacy requests an extension after
the deadline has passed, Humana will not grant the extension.
13. Q: When can my pharmacy expect to receive an audit report?
A: To comply with state laws and contractual requirements, Humana strives to review audit
materials in a timely manner.
- For onsite audits, the initial finding report is typically sent within seven to 10 days of
the audit. The final audit report is typically sent within 30 days of the deadline.
- For desktop audits, all audit reports are typically sent within 30 days of the audit
deadline.
14. Q: What type of discrepancy can I supply additional documentation for during post audit?
A: As per section 6, the Humana Pharmacy Solutions audit discrepancy code list, outlines what
is acceptable for each discrepancy type during post audit.
15. Q: What type of discrepancy can I appeal?
A: An appeal can be submitted on any claim marked discrepant, as long as the appeal is filed
under the guidelines in section 6.2 of this audit guide, using the Pharmacy Audit Appeal Form.
16. Q: Who reviews my appeal?
A: The Humana Pharmacy Appeals Committee, which is composed of several associates from
numerous functional areas within Humana.
17. Q: My pharmacy provides other services such as delivery and drive-thru services to our patients.
For these members, rather than require the patient to sign a signature log, we write “mailed,”
“delivery” or “drive thru” to show that this prescription was delivered. Is this practice
acceptable?
A: No. The pharmacy handwriting “mailed,” “delivery,” “drive thru” or other interpretation does
not validate that a patient has his/her medication. The pharmacy should provide a delivery
manifest or patient statement. Humana does not accept the signature of the courier or delivery
driver as proof of delivery.
18. Q: Will I receive a final/estimated charge back amount with my audit result?
A: Yes. You will receive an estimated charge-back amount on all audit findings. The true and
final amount cannot be calculated until the claims are adjusted and will appear on the pharmacy
remittance statement.
19. Q: How and when will recoupments/penalties take place if applicable?
A: Recoupments/penalties will take place within 30 calendar days of the audit closing, meaning
all appeals have been exhausted. Recoupments/penalties will be offset from future claims
payments.
20. Q: How long do I have to file an appeal?
A: Appeals must be submitted on an appeal form and postmarked within 15 calendar days from
the date of the final results letter.
21. Q: Who should I contact, with any questions about my audit?
A: For Humana desktop audits, call 502-580-3232 or e-mail [email protected]
For Humana onsite audits, call 215-551-3838
For Argus audits, please e-mail [email protected]
For appeals, please e-mail [email protected]