PBM

The PBM is the highest level.  There are platform settings which will provide overall impacts to the benefit plans established in the PBM.  It is at this level that the Brand Class is established.

Below is a sample PBM record.  The Critical items include the PBM Name, PBM ID (located near the  button), effective start and end dates, and the Claim History Window.

 

• EFF START: The Effective Start date is the earliest a date of service claim can process. We recommend back dating this to a date before any claims history dates of service. A date of 01/01/2000 is fine.
• EFF END: This is the Effective End date. This date we recommend to be the system end of time date, 12/31/9999.
• DEFAULT GROUP: The Default Group is designed for a future enhancement. At this time, do not populate this field.
• PCN USAGE: This is to be used in conjunction with the Default Group in the future. This field should remain at NONE at this time.
• CLAIM HISTORY WINDOW: This is the maximum days that a claim’s date of service can be from the adjudication date. There are other options within the system that allows you to fine tune the processing periods. We recommend a window of 365 days to account for manual claims. Again, additional settings are available at the group and plan level to control these windows.
• ALLOW ZERO U&C: This would allow claims without a populated U&C field to process. We recommend that this be left in the off position.
• BIN/PCN Routing: This would allow claims to be adjudicated against a specific group based on the BIN/PCN in the claims irrespective of the submitted group ID. Please refer to this document for more details on the functionality.

The next section of the PBM record addresses ID Card Production services. The system allows for ID Card setup information at various levels.

CARD STATUS: The Card Status is the first step. The options include:

• Cards: Card requests that reach the PBM level will use the associated VENDOR settings.
• No Cards: No cards are produced for any requests that reach this level.

ID CARD PRODUCTION: ID Card Production is a record that indicates how the card request will process and for which card vendor. This field is required IF the Card Status is set to Cards. Available ID Card Production records are listed on the right of the screen.  The ID Card Vendor setups are created in Administration/Vendor Management.

 

ADD CONTACTS: We provide the ability to add Contacts to the PBM record.  

 

Brand Class

The Brand Class is where the PBM defines the Brand Class for a drug.  The options supported are

• Brand Multi-Source,
• Brand Single Source,
• Generic Multi-Source, and
• Generic Single Source.

The Brand Class setup is driven by Criteria.  This can be as simple as using the MediSpan Multi Source Code of MONY to a specific select NDCs.  The Brand Class functionality is dependent on the created Criteria

The process is straightforward.  Criteria are established based on your business needs.  Each Criteria should reflect a specific Brand Class (Generic SS, Generic MS, Brand SS, Brand MS).  These criteria are added to the PBM record using Manage Rules (option showed when clicked on the ellipse icon).    The Brand Class rules are prioritized, and you will see the Priority # assigned.  If a drug is reflected in more than one criteria, the first criteria (priority) that the drug qualifies for will be used for Brand Class during claim processing.