EDIT - Refill Too Soon

Refill too Soon (RTS) allows control over when a prescription can be refilled.

NOTE:

Compounds are validated for Refill too Soon based on Provider ID and Rx Number.

Edit Name is the unique name for the edit.

Claim Type

This edit will apply to the following claim types.

• ALL (POS and DMR)
• Point of Sale (POS)
• Direct Member Reimbursement (DMR)

Look Back Start

The earliest number of days, from the claim date of service, to look back into the Member claim history.

Look Back End

The latest number of days, from the claim date of service, to look back into the Member claim history.

Message Group is the assigned Message group to be captured each time the edit is used.

From Day

Lowest value is 0.

Thru Day

Last value in last range must be 999 (or largest allowed day value).

Minimum Type

• Days Used (of preceding claim):  This is the number of days the member would have taken the medication on the claim.  As an example, if the original claim was filled (date of service) on January 11th, and the refill date of service is January 15th, the days used is 5 days.  The date of service of both claims are included in the calculation as the member can start the medication on the first date of service.  On days used calculation, the days supply will always be rounded up.
• % Used (of preceding claim): As an example, if the original claim was filled (date of service) on January 11th with a day’s supply of 7, and the refill date of service is January 15th, the % used is 71.43% (5 ÷ 7 = 0.71428).
• Both:  This Type requires both Minimum Days Used and Minimum % Used are satisfied for the refill to continue to process.
• Either:  This Type requires that either Days Used OR % Used is satisfied for the refill to continue to process. 

Minimum Days Used

What is the minimum number of the days supply that must be used before the prescription can be refilled.

Minimum % of Drug Used

What is the minimum percentage of the days supply that must be used before the prescription can be refilled.

Action Type

The actions available dictate how the claim will be treated IF the claim does not qualify yet for a refill.

• Reject, Hard (online override not allowed)
• Reject, Soft (Allows provider to submit override - use of OVERRIDE EDIT)
• Reply (message back to the provider).  Claim continues to process.  No reject occurs due to Refill Too Soon.

Add Another Range

Ability to add another Refill too Soon range