162x Filetype PDF File size 0.73 MB Source: www.express-scripts.ca
Pharmacy Provider Manual APPLICABLE TO ALL PROVINCES AND TERRITORIES (EXCLUDING QUÉBEC) December 2019 Version 5.0 @ExpressRxCanada Express Scripts Canada Express Scripts Canada 2019 Express Scripts Canada. All Rights Reserved. Any comments or requests for information may be transmitted to: Express Scripts Canada Attention: Provider Relations 10th Floor 5770 Hurontario Street Mississauga, ON L5R 3G5 Express Scripts Canada reserves the right to update this manual and content referenced in this manual. Data used in examples are fictitious unless otherwise noted. In the event that there are discrepancies between the English and the French version, the English version will prevail. © 2009 – 2019 Express Scripts Canada. All Rights Reserved. Express Scripts Canada is a registered business name of ESI Canada, an Ontario partnership. All reproduction, adaptation or translation is prohibited without prior written authorization, except for cases stipulated by the Copyright Act. Registered or non-registered trademarks and registered product names belong to their respective owners. @ExpressRxCanada Express Scripts Canada Express Scripts Canada 2 2019 Express Scripts Canada. All Rights Reserved. DOCUMENT REVISION HISTORY Version Date last revised Publication date Details 1.0 December 2010 December 2010 Revision 2.0 November 2012 November 2012 Revision 3.0 April 2016 April 2016 Revision 3.1 February 2019 April 2019 Revision 4.0 June 2019 July 2019 Revision 5.0 December 2019 December 2019 Revision Note: The publication date takes precedence over the date last revised. @ExpressRxCanada Express Scripts Canada Express Scripts Canada 3 2019 Express Scripts Canada. All Rights Reserved. Table of Contents 1. DEFINED TERMS ...................................................................................................................................................................... 6 2. INTRODUCTION ......................................................................................................................................................................... 9 2.1. Purpose ........................................................................................................................................................................... 9 2.2. Terms ............................................................................................................................................................................... 9 2.3. Exemptions ...................................................................................................................................................................... 9 2.4. Role of Express Scripts Canada ................................................................................................................................... 10 2.5. Express Scripts Canada Services ................................................................................................................................. 10 2.6. Express Scripts Canada Clients ................................................................................................................................... 11 3. PHARMACY PROVIDER AGREEMENT ..................................................................................................................................... 12 3.1. Pharmacy Provider Agreement ..................................................................................................................................... 12 3.2. Liability Insurance and Indemnity ................................................................................................................................ 12 3.3. Pricing – Same Level Playing Field .............................................................................................................................. 13 4. AUDIT AND REVIEW PROGRAM.............................................................................................................................................. 13 4.1. Audit ............................................................................................................................................................................... 13 4.2. Audit Response ............................................................................................................................................................. 14 4.3. Provider Responsibility ................................................................................................................................................. 14 4.4. Review ........................................................................................................................................................................... 15 5. ADJUDICATION SYSTEM OVERVIEW ...................................................................................................................................... 16 5.1. Real-time Processing .................................................................................................................................................... 16 5.2. Adjudication System Functionality ............................................................................................................................... 16 5.3. Variations in Pharmacy Practice Management Systems (PPMS) ............................................................................... 16 6. ENROLMENT AND MODIFICATION TO PHARMACY PROVIDER INFORMATION .................................................................... 16 7. CLAIM REIMBURSEMENT PROCESS ..................................................................................................................................... 17 7.1. Pharmacy Provider Reimbursement ............................................................................................................................ 17 7.2. Net Reimbursement ...................................................................................................................................................... 17 8. CLAIM SUBMISSION PROCESS .............................................................................................................................................. 18 8.1. Claim Submission Requirements -- General ................................................................................................................ 18 8.2. Direct Electronic Claim Submissions ........................................................................................................................... 19 8.3. Deferred Claim Submissions ........................................................................................................................................ 20 8.4. Manual Claim Submissions – Claims Exceeding $9,999.99 ..................................................................................... 20 8.5. Compound Claim Submissions .................................................................................................................................... 21 8.6. Methadone and Suboxone® Claim Submissions ....................................................................................................... 22 8.7. Medical Cannabis Claim Submissions ......................................................................................................................... 22 9. CLAIM REVERSALS ................................................................................................................................................................. 22 9.1. Electronic Claim Reversals ........................................................................................................................................... 22 9.2. Deferred Claim Reversals ............................................................................................................................................. 23 9.3. Manual Claim Reversals ............................................................................................................................................... 23 @ExpressRxCanada Express Scripts Canada Express Scripts Canada 4 2019 Express Scripts Canada. All Rights Reserved.
no reviews yet
Please Login to review.