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picture1_Expressscriptscanada Pharmacy Provider Manual En Version 0


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File: Expressscriptscanada Pharmacy Provider Manual En Version 0
pharmacy provider manual applicable to all provinces and territories excluding quebec december 2019 version 5 0 expressrxcanada express scripts canada express scripts canada 2019 express scripts canada all rights reserved ...

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         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. 
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...Pharmacy provider manual applicable to all provinces and territories excluding quebec december version expressrxcanada express scripts canada rights reserved any comments or requests for information may be transmitted attention relations th floor hurontario street mississauga on lr g reserves the right update this content referenced in data used examples are fictitious unless otherwise noted event that there discrepancies between english french will prevail is a registered business name of esi an ontario partnership reproduction adaptation translation prohibited without prior written authorization except cases stipulated by copyright act non trademarks product names belong their respective owners document revision history date last revised publication details november april february june july note takes precedence over table contents defined terms introduction purpose exemptions role services clients agreement liability insurance indemnity pricing same level playing field audit review ...

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