When you submit a claim, it’s probably so routine that it requires little thought. But when you have a question about an unusual claim or about complying with regulations, do you know where to turn?
The answers you seek can likely be found in payer sheets. Payer sheets are documents produced by pharmacy benefits managers (PBMs) that detail the appropriate processes for submitting claims.
Each PBM produces its own payer sheet, and some PBMs produce a payer sheet for each plan. These documents are typically updated annually, but PBMs can make more frequent adjustments if necessary.
Here’s a look at what you need to know about these important PBM documents.
Importance of payer sheets
Payer sheets outline detailed information about how to correctly process claims. They also define the required fields of information for processing a prescription claim, such as BIN number and process control number (PCP).
Payer sheet address specific plans’ and PBMs’ policies regarding:
- Coordination of benefits (COB)
- Processing 340B claims
- Processing long term care claims
All of this information should be accessible through your pharmacy software system, but you can refer back to the original PBM-issued payer sheets if you have any questions.
Payer sheets are different from provider manuals
Payer sheets differ from provider manuals, which are documents produced by PBMs that outline regulations and requirements that pharmacies must adhere to.
Payer sheets typically focus on claims processing, and following the specifications outlined in payer sheets is an important step to prevent—or be prepared for—audits.
Payer sheets and HIPAA
Payer sheets used to be in a format known as version 5.1, but in 2012, the NCPDP Standard Format was updated to comply with the Health Insurance Portability and Accountability Act (HIPAA). The updated format that all pharmacies should now be using to process claims is version D.0.
Payer sheets and software
PBMs require pharmacies to use software that adheres to the most up-to-date NCPDP standards and HIPAA regulations.
Check with your pharmacy’s software vendor to make sure its system is up-to-date and HIPAA-compliant.
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