Procella HelpdeskThe Refill Limit edit enables additional controls on the refill of prescriptions.
Edit Name is the unique name for the edit.
Max Refills
This is the maximum number of refills allowed for the drug at the GPI-14 level.
Days from Initial Rx
This compares the date of service from the first/oldest claim (same GPI14, earliest claim in lookback period) to the date of service from the current claim.
Days of Total Therapy
This is the maximum days for the drug, calculated on the date of service of the initial claim (same GPI14) to the date of service on the current claim PLUS the Day Supply on the current claim.
Days for Total Therapy
This is the maximum days from the initial claim date of service to the current claim’s date prescription written.
Lookback Period
The number of days to search in claim history for matching drug (GPI-14 level). Uses the date of service of the current request claim and subtracts the Lookback Period. Any net paid claim (paid claim with no reversal) that has a Date of Service in the Lookback period is part of the claim history reviewed in this EDIT.
All 4 evaluations (Max Refill, Initial Rx, Therapy, Initial Therapy) must evaluate as true for the claim to pass and continue processing.
Message Group is the assigned Message group to be captured each time the edit is used.
Notes:
The Refill Limit EDIT controls the number of times a drug can be refilled on the plan. Alternately, this EDIT can override refill limits (unlimited). This EDIT also allows additional controls on refills.
The original first fill is 0, the remaining are 1-99 (refills). Unfortunately, the Fill Number is not always accurate nor does it take into account the possibility the same drug was filled at a different facility for the member (retail and mail order for instance).
Filled Claim Count is the # of net paid claims in Claim History with the same Member ID and GPI-14
ClaimHistory is found by looking for a match with same Member ID and GPI-14 with a date of Service during the Lookback Period.
First Claim is the oldest paid claim within Claim History for matching combination of fields. [ClaimHistory.FirstClaim.DateOfService]