Procella HelpdeskThe Dispensing Fee edit is used to calculate the dispensing fee for the claim. The dispensing fee edit has many available options to support the varied requirements in the industry. In addition, each dispensing fee edit has separate calculations for Brand Single Source, Brand Multi-Source, Generic Single-Source and Generic Multi-Source.
The first requirement is to Name the edit. This name must be unique among all edits, not just dispensing fee.
Calculation Type
The next requirement is to establish the calculation type for the dispensing fee. The calculation type must be selected to move on to the next steps as each type has different requirements.
Days Supply Multiple
The days supply multiple enables a dispensing fee to be a specific multiplier of the days supply. For example, for every 30 days of supply on the claim, the dispensing fee will be a multiple of $2.00. Therefore, if a claim had a 90 days supply, the dispensing fee would be $6.00.
When Days Supply Multiple is selected, the multiplier is entered next.
Fixed
This is the more common dispensing calculation type. This is a set fee without regard to the days supply of the claim.
Tiered by Days Supply
The Tiered by Days Supply enables up to 5 different ranges of days supply to have different dispensing fees.
Message Group
The next option is to assign a message group.
Subset
The next section is the subset. The Subset represents the STATES that the pharmacy is located. A dispensing fee edit cannot have a state represented in more than one Subset. So, if you have a subset for HAWAII, the additional subset cannot include HAWAII.
Each subset requires a name that is unique for all dispensing fees.
The next step is identifying which states will have the dispensing fee calculated. By clicking on the States dropdown, you can select which states will have the dispensing fee applied. If all states and territories are included, click on the All States. Click on the Select label above the SELECT ALL to collapse the State Card.
If dispensing fees vary based on state, a new subset will be required. In the initial State selection, select the state(s). Then setup the appropriate rate rules.
For the next set of States, click on Add Subset. Name the subset and select the States for the next calculation of dispensing fees.
Rate Rules
While each dispensing fee calculation type has different requirements, they all share the same dispensing fee setup.
Let’s start at the base of the calculation. The first item to select is the Basis Cost. This allows a different dispensing fee to be calculated for different ingredient sources. For instance, if AWP is used, there can be one calculation. For a specific MAC list, another dispensing fee can be calculated.
Within each brand class, there is also a requirement for a DEFAULT basis of cost. This is used if when there is no basis of cost that matches a specific dispensing fee basis of cost. For instance, if GOLDMAC was used for the ingredient, but there was no dispensing fee setup for GOLDMAC, then the default calculation would be used.
There are two fields associated with FLAT AMOUNT. One is the numeric sign, +/-/none. If the flat amount of the dispensing fee is positive, select +. If negative, select -. If there is no flat amount component to the dispensing fee use none (which will be empty). If a flat amount is to be used, enter it into the FLAT AMOUNT field.
NOTE: If you have a sign ( + / - ) associated with the FLAT AMOUNT but no numeric value, this will cause a problem. If the FLAT AMOUNT is not used, leave blank or select NONE. This applies to % AMOUNT as well.
There are two fields associated with % AMOUNT, or percentage amount. One is the numeric sign, +/-/none. If the % amount of the dispensing fee is positive, select +. If negative, select -. If there is no % amount component to the dispensing fee use none (which will be empty). If a % amount is to be used, enter it into the % AMOUNT field.
If a combination of both flat amount and % amount are used to calculate the dispensing fee, how those values will be used in calculation must be selected. This occurs in the calculation type field of the dispensing fee calculation. The options are to calculate the fixed amount first and then the % amount or % amount first and then the flat amount.
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(Ingredient * Percent%) + Flat$ 100 * 10% = 10 + 5.00 = $15.00 (Ingredient + Flat$) * Percent% 100+5.00 = 105.00 * 10% = $10.50 |
MIN AMOUNT is required when a % AMOUNT is used. The minimum amount must be at least $0.01 and not exceed the MAX AMOUNT.
The MAX AMOUNT is required when a % AMOUNT is used. The maximum amount must be greater than the MIN AMOUNT.
Within one Dispensing Fee edit, multiple basis of cost codes can be assigned. Simply add a row using the icon in the lower right corner of the edit.
Each brand class, including Default, will require setup. That should be the standard approach. If a DEFAULT brand class is setup and the other Brand Classes are not, the claim will use the DEFAULT brand class.
Each Brand Class, including Default, may have one or more Rate Rules.
Each Subset may have different rate rules than another within the Edit.
Below is a sample screen of 2 subsets is below.
Subset 1 (Test Subset 1) is for all states EXCEPT Alabama and Alaska. It includes a rate for DEFAULT and a Rate for AWP.
Subset 2 (SUBSET 2 AL ALASK) is applied only to Alabama and Alaska. It includes 3 rate rules: DEFAULT, AWP and U&C.
