Customer Service is a critical element of any claims processing system.  The information should be easy to find, and even more important, easy to understand. 

• Login to the Procella Platform, and select the PBM.
• Click on the Primary Menu. You will see several icons, including Customer Service.

Click on the Customer Service Icon.  The Customer Service group has a sub-menu of options for the User.  You will most likely land on the Customer Service, Claim History screen.  

The menu covers the following functions:

• Card Management:  This is the ID Card Requests that have been made on behalf of members.  On this screen, you can search and review Member ID Card requests.  You cannot initiate a card request from this screen, but you can cancel an existing request. This has not been fully integrated, so its [Currently Unavailable]
• Claim History:  The Claim History screen is where you will spend the majority of your Customer Service time.  It is this screen that searches for claims based on the filter criteria you set.
• Claim Submission Tool:  The Claim Submission tool allows you to submit a claim.  This process is used extensively in testing but also supports the ability to process a Member DMR (Direct Member Reimbursement) claim.
• Drug Lookup Tool:  The drug lookup tool provides search capabilities into the Drug File and their associated prices.
• Member:  The member screens are all about the Member.  This includes Eligibility, Benefit Coverage, drug authorizations, ID Card Requests, and Alias Data.

Claim History

The Claim History screen is where Customer Service representative spends most of their time.  We will examine the varied areas to understand the information presented.

Search Screen

The Search Screen is geared to find the claim of interest quickly and easily.  We have 9 fields which are the most common elements used to find a claim.

Provider ID

The Provider ID is the ID number the pharmacy used to process the claim.  In most instances, this will be the NPI or National Provider Identifier.  Another common ID is the NCPDP, or National Council for Prescription Drug Programs, ID.  This is the industry ID assigned and managed by NCPDP.

Cardholder ID

The Cardholder ID is the member’s assigned ID and is submitted by the Pharmacy Provider.

Adjudication Date/Time

The ADJ DATE and TIME fields are related to the date and time the Pharmacy Provider submits the claim.  The Time is based on Eastern Standard Time.

The ADJ DATE & TIME FROM is the earliest date and time to begin the search and the time is set to be 15mins earlier than the current time so that when the user clicks the search button, it automatically brings claims that are adjudicated in the last 15mins.

The ADJ DATE & TIME TO is the latest date and time to end the search.  When you are working with many claims, it is best to focus on a narrow date/time range.

The Adjudication from and to fields are the only required fields for the claim search screen.  This helps performance.

 

HELPFUL HINT:  In most cases, you will receive a call from the providing pharmacy provider soon after the claim is processed.  Many times, this is due to a rejection.  We have found it easiest to set the ADJ DATE & TIME TO tomorrow’s date.  This keeps the user from resetting the TO date/time repeatedly.

 

Service Date

As noted above, the adjudication date is when the Provider processes, or adjudicates, the prescription.  The Service Date can be different from the adjudication date.  The Service Date, also known as the Fill Date, is when the pharmacy Provider fills the prescription.  There are several reasons that the Service Date is on or before the Adjudication Date.  In addition, note that the Service Date does not have a time associated.  There is no time associated with the Service Date.

The Search screen allows you to provide a FROM and TO date range to the Service Date.  When the Service Date FROM and TO are set to the same date, you are searching the one date.  Therefore, consider the TO date to be inclusive of the date you are entering, or a through date. 

 

Claim Status

Claim Status is useful for claim searches.  The Claim Status is the result of the processed claim.  The primary statuses within the system are as follows

• Rejected
• Paid
• Reversal:
• Denied:

We have tried to keep the status names straightforward.  But there are some nuances.

Rejection

A Rejected claim is one where, based on the benefit design, the claim does not qualify for coverage for one or more reasons.  For instance, the patient is not covered, or the cost exceeds maximum are typical benefit design rejections. 

Paid

A Paid claim indicates that the claim passes all the rules of the benefit design and is therefore covered by the plan.  As this is a “clean” claim, there are no rejection messages.

Reversal

A reversal occurs when the Provider has already submitted a Paid claim and wishes to “recall” that claim from consideration.  This may be due to the member not picking up the prescription to the pharmacy Provider seeing something incorrect on their end.  The Reversal nets out the Paid claim. 

Denied

A Denied claim is a claim that fails the initial processing.  This could be due to a missing field from the Provider being a duplicate of an existing claim.  Ultimately, a Denied claim is one where benefit coverage cannot be considered given the information provided.

Duplicate of Approved

The Duplicate of Approved status is a denied claim that specifically identifies a duplicate of a claim that has already been Approved.  This status has a low likelihood compared to other Status types.

Member Name

The filter options include the Member’s name as submitted by the Provider.  You have the option of the First and/or Last Name.  You can use partial names for searching. 

Filter Settings

Customer Service agents come from many aspects.  They bring different approaches to supporting callers.  It is only logical that many Customer Service users will require different filters or search settings.  Rather than use valuable screen space with filters that may not help Customer Service agents. we have enabled additional filter settings for use. 

To access these additional filter settings, simply click on the gear icon.  When clicked, the user is presented with multiple filter options.  By clicking on the + sign, the User selects the filters to apply to the search screen.  In the image above, the Provider Name and Group ID are selected while the others, including Prescriber ID, are not. 

Provider Name

Provider Name is the name of the Providing Pharmacy.  A partial

Prescriber ID

A Prescriber ID is what the Provider submits as the ID representing the Physician or Prescriber of the drug.

Group ID

The Group ID is submitted by the Provider pharmacy to assist in matching the claim to the benefits.

Rx#

The Rx# or prescription number is the number the Provider assigns to the claim in their pharmacy and submits on the claim. 

NDC/Product ID

The NDC, National Drug Code, or Product ID is the 11-digit ID number that reflects the drug being dispensed by the provider.

Claim Type

The Claim Type represents the type of claim submitted.  Options include POS (Point of Service) or DMR (Direct Member Reimbursement).  A POS claim is one submitted by the Provider through the online adjudication process.  A DMR claim is one that the PBM team enters and processes manually. Enter 1 or 2 in the claim type field to filter POS and DMR claims.

1 - Represents POS claims

2 - Represents DMR claims

Transaction Type

This option is currently not supported. [Currently Unavailable]

Transaction Claim ID

The Transaction Claim ID is the internal claim system’s ID number for the transaction.  This is important from a data perspective.  Why?  Because this ID is never duplicated and is therefore Unique to the claim within the PBM.

Drug Name

This is the drug name for the NDC/Product ID submitted by the Provider.

Standard and Test Claims options

Selecting this radio button option is an important part of the search.
By default Standard is selected, this will list all the standard claims per the search criteria. Here standard claims refer to claims submitted by the pharmacy, standard POS/DMR claims submitted from the claim submission tool.
Test-Claims are the test claims submitted from the claim submission tool. 

Claim History Search Results

The Claim History Search Results are the claims that meet the filter criteria you have set up.  Once you have completed the filter setup as needed for the search, click on the SEARCH button.  Your results will be listed below the search area.
The Search Results actually provide more data than initially presented.  The claim listing will show you the Provider ID, the basic drug name, the cardholder ID, the Service date, the adjudication date/time, and the claim’s status.  But there is more.
Caret Icon
The caret icon is used throughout the system (in almost all the list screens), and especially in the Customer Service screens.  The caret expands the information on the current record to show more detail.  This can assist in answering questions.

PAID Claim

The example above shows the original record (the top line of the image) and some detail about the claim.  As noted, this helps identify if this is the correct record to dig into further. 

REJECT Claim shows the reject reason for quick reference

Ellipsis Icon

The ellipsis is used throughout the system as a sub-menu for a record.  By clicking on the ellipse, you will see different options (as available) for the record. 

For most claims, the option on the Ellipse is to View Claim Summary.  On a Paid claim, there is an additional option, Reverse Claim. 

The option to Reverse a claim enables the User to reverse a PAID claim that is not otherwise reversed.  This may be requested if the Provider is having difficulty reversing the claim online.

The View Claim Summary allows the User to open the selected claim and see various detail about the claim.  This is one place where, after left clicking on the ellipse to open the sub menu, you can right click and open the record in a different tab or window, depending on your preference.  This is sometimes preferable, so your search criteria/filter remains as you set it.

Claim Review

Select View Claim Summary from the search screen ellipse option for the claim in question.   There are many parts of the claim screen, logically grouped for easy access.  You will see various tabs across the screen for quick access to specific areas.  We will delve into each area.

NOTE

For most screens, where codes are used, the description of the code is also provided.  We find this helps with training and quicker identification of information.

Claim Header

At a top of each claim screen is a claim header.  This header is consistent regardless of the different screen areas reviewed.  The claim header presents general claim information such as member, drug, dates, status, and notes indicator. 

Notes

The Notes function allows the User to create, and delete notes.  These notes may be associated with the claim or with a member.

Summary

The Summary tab contains 4 primary areas of information about the claim submitted.  The member information, provider and prescriber information, claim information, and messages. 

Each of these buckets of information is considered a Card.  The Card can be expanded and collapsed using the caret icon.  All cards are expanded when you

Member Info

The member information reflects who the claim is for and basic information about that member.  This is information as submitted by the Providing Pharmacy. 

Messages

The Messages card provides the messages created during the processing of the claim.  While messages can and do occur on a paid or reversed claim, most messages occur when a claim is rejected.

In the example, left, the reject was due to the days supply on the plan being exceeded by the days supply on the claim. 

The messages card will contain the messages that are generated for the Provider.  Additional messaging is available in the Transaction section of the claim which reflects the messaging capabilities of the benefit design.

Provider & Prescriber

The Provider and Prescriber card contains the information about the Providing Pharmacy and the submitted Prescriber.

Provider

The Provider information is important.  This captures the Provider ID, in most cases the NPI for the Provider.  In addition, the address and telephone number are presented if populated.

Some important information captured is the Provider Network the pharmacy was part of for processing.  The Network Classification, in or out-of-network pharmacy, and the Network Type.  The Network Type is your classification for the network, with options of Retail, Retail90, Mail, and Specialty. 

Prescriber

The Prescriber information is the data from the Provider.  This includes the prescriber's first and last name, the Prescriber ID (typically the NPI or DEA ID), and some demographic information.

Claim

The Claim card includes a lot of information based on the data submitted by the pharmacy.

Claim

The claim section of the card provides general information.  The key information here includes:

• RX Ref # (Rx Number)
• Quantity
• Days Supply
• DAW – Dispensed as Written
• New/Refill 

Drug

The Drug section provides key elements about the drug, including Product Service ID (NDC currently), and Drug Name.  There are 2 brand classes listed for the Drug, Brand Class, PBM, and Brand Class, Priced.  The Brand Class, PBM is the brand class of the drug before any processing of the claim.  The Brand Class Priced reflects the class IF the rules applied change something.  For instance, for DAW 5, Brand Drug dispensed as Generic, the system recognizes that the drug is a Brand.  But, the Pharmacy is stating that the drug is being used for this claim as a Generic.  In this case, the Brand Class, PBM would be Brand Multi-Source, and the Brand Class, Priced would be Generic Multi Source.

Financial

The financial data is the submitted data from the pharmacy with the exception of the Net Amount Due.

Benefit

The Benefit information reflects the submitted group, adjudicated group, and benefit plan used for processing the claim.

The Submitted Group ID is what the pharmacy submitted on the claim.  There are times when what was submitted does not match what group was used in adjudication.

The Group ID reflects the group ID the claim was adjudicated against with the description of the group.  The Plan ID is the benefit plan used.

Claim

The Claim tab contains additional information about the claim than presented in the Summary screen. 

Claim

While many of the elements of the Summary tab are presented on this screen, more information is available.  Of note are formulary statuses as set up on the benefit plan. 

Messages

This is the same message information as provided on the Summary screen.  The information is posted here to reduce the amount of screen jumping and screen scrolling the user undertakes.

Drug

The Drug card is an in-depth view of the drug dispensed by the pharmacy.  The goal is to provide important information without the need to look up the drug independently. 

Provider & Prescriber

The Provider and Prescriber tab provides additional details on the pharmacy and the prescriber.

Provider

The Provider detail includes information your organization has populated in Provider Manager.  This includes adjudicated network information as well as the services this pharmacy provides. 

Prescriber

The Prescriber card provides more information on the prescriber.  This area is similar to the provider above. 

Financial

The Financial tab is where all the financial information resides.  There is a lot of information, and we continue with the grouping of similar information.

Finances

The key Finances card is where much information is available.  Notice there are three columns of financial information; Submitted, Provider, and Plan.

The Submitted column reflects the financials as submitted on the claim. 

The Provider column reflects the financial values communicated back on the response to the pharmacy. 

The Plan column reflects the financials as charged to the Plan, or Client.

The top 2/3rds of the Finances card are the primary financial elements.

The bottom third reflects the tax implications at the detail level. 

Fees

The Fees card captures any fees that are generated during the processing of the claim.  The 2 columns reflect the financial responsibility of any fees. 

Other Finances

There are 3 sections within the Other Finances card.  The most important is the Member Pay section. 

Member Pay

The Member Pay amount can have various elements included in the cost the member is responsible for.  The fields reflect the standard NCPDP fields which calculate to the Member pay.  The total of this card section is presented in the Finances card in Member Paid Amount.

The reason this section is detailed is to better understand how the member pay total is represented.  From deductible to tax, copay, DAW/product selection, all of this is important to the Customer Service agent in answering questions. 

Rebates

The Rebates section reflect the Point of Sale (POS) rebate process as it is applied to this claim.  The POS Rebate can be credited to the Member, Plan (Client), or the Provider as determined by the PBM.

General

The General section provides the total AWP before the discount for the claim.  Even when the claim is priced using other than AWP, the Total AWP will reflect 100% of the calculated AWP.

The Unit Cost per Rx is simply the cost of the claim divided by the Quantity.  The Unit Cost/Ingredient is the ingredient cost of the claim divided by the quantity.

These values are for reference and can be helpful to the User.

Transaction Data

The Transaction Data tab has an extensive amount of information.  First, it presents each segment of the NCPDP claim into easy-to-read elements.

Below are the Transaction Segments and the additional information added for use.

• Transaction Header
• Patient
• Insurance
• Response Message
• Response
• Claim
• Prescriber
• Pharmacy Provider
• Pricing
• Coordination of Benefits/Other Payments
• Compound
• DUR/PPS

While the following segments are captured during processing and available in the Raw Claim view, separate screens have not been implemented.

• Workers Compensation
• Coupon
• Clinical
• Additional Documentation
• Facility
• Narrative

Additionally, the Transaction Data tab provides 3 Procella segments, Raw Claim, Rules Audit and Messages.

• Raw Claim :  This view provides the detail of the raw claim and its associated JSON view.
• Rules Audit :  

When a user clicks on "Transaction Data" -> "Rules Audit," it will display all PBM & Plan rules applied to the claim. This feature captures all plan-level rules for the specific claim, which are adjudicated against a plan setup.

The "Rules Audit" segment includes a special filter that allows users to sort the displayed rules based on whether they were applied to the claim ("YES") or not applied ("NO"). Currently, "ALL" is set as the default value, showing all rules present in the plan setup against which the claim was adjudicated.

Importantly, the rules audit filter operates based on the "RULE APPLIED" column, not the "CRITERIA MATCHED" column.

 

The "Rules Audit" provides the following information:

RULE HIERARCHY	This shows the hierarchy level where the rules are present in the plan. For example - Plan Default, Plan Exception and Plan Complex.
RULE TYPE NAME	This displays the category type of the rule set up at the plan level, such as coverage rules, adjudication rules, clinical rules, etc.
RULE NAME	The name of the rule entered by the user during rule creation.
CRITERIA ID/VERSION ID	Displays the criteria ID and version ID, which the user dragged into the plan rule setup or inline criteria created by the user.
CRITERIA NAME	The name of the criteria entered by the user during creation and dragged into the plan rule setup.
CRITERIA MATCHED	Indicates whether the criteria matched or passed for the specific claim/NDC. "YES" indicates a match, while "NO" indicates no match.
METADATA CATEGORY	Displays the category name of the edits, such as Copay, Coinsurance, Ingredient Cost, etc.
METADATA NAME	The name of the edit entered by the user during creation.
RULE APPLIED	This final column determines whether the rules is applied or not.  There is a possibility that Criteria got matched but rule was not applied. For eg., Criteria conditions says 'Exclude OTC Drugs' If the drug in claim is OTC, then Criteria matches and the rule will not be applied because of 'Exclude' in the Criteria

• Network Rules Audit :

When a user clicks on "Transaction Data" -> "Network Rules Audit," it will display all Provider Network rules applied to the claim. The Provider Network Rules is applied when the PRICING METHODOLOGY set as Provider Pricing for Client Pricing.

The "Network Rules Audit" segment also includes a filter that allows users to sort the displayed rules based on whether they were applied to the claim ("YES") or not applied ("NO"). The default value is "ALL," which shows all rules present in the Provider setup against which the claim was adjudicated.

Importantly, the "Network Rules Audit" filter operates based on the "APPLIED" column.

The "Network Rules Audit" provides the following information:

CRITERIA ID/VERSION ID	Displays the criteria ID and version ID that the user dragged into the provider setup.
CRITERIA NAME	The name of the criteria entered by the user during creation and dragged into the provider rule setup.
METADATA NAME	The name of the edit entered by the user during creation.
METADATA CATEGORY	Displays the category name of the edits, such as Copay, Coinsurance, Ingredient Cost, etc.
APPLIED	This final column determines whether the claim was adjudicated against specific rules present in the plan. It displays "YES" or "NO".

Accumulators

This Tab provides information on the financial and claim accumulations.

Financial Accumulators 

This section shows about the amounts attributed per member for the current benefit year( Jan-Dec) to the date of claim adjudicated.

• $ ATTRIBUTABLE TO CLAIM  - It shows only the amount that the current claim adds to accumulation.
• $ MONTH TO DATE -  It will show the sum of claim amounts for the current month (month at which the user viewing claim is adjudicated ) for that particular member.
• $ BENEFIT YEAR TO DATE  -It will show the sum of respective claim amounts for the current benefit year (Jan - Dec) for that particular member.

Claim Accumulations/Limitations [Currently Unavailable]