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**goes kaboom** Sometimes, pharmacists make me want to either go on a random killing spree or just kill myself.
Basic needed info:
I got a pharmacy support call on one of our discount cards. Basically, she was submitting a claim to us for reimbursement, and it was being rejected. The reason why is because the card is designed as an insurance copay assistance card ONLY: that means, the card will ONLY pay on the claim if they include information about the primary insurance and that they paid on the medication, too.
The reason for it is that the medication is astronomically expensive. There's seperate programs for when the patient doesn't have insurance, so when they do have insurance, we give them this card. We made that rule about only paying on copays so pharmacists don't process it wrong and charge the patient $1,000-2,000 by mistake.
It's a good system. However, our computers give a generic rejection message because the program isn't intelligent enough to know why certain things don't match.
Her: "I'm getting a non-matched group number rejection message, could you help me with that?"
Me: "Certainly." *gets info*
-Sometimes the group doesn't match. Usually it does. What it REALLY means is there's no program that matches what the pharmacy is submitting... because they're not following the program rules, not because they're using the wrong group number.
Me: "Ok, looks like what the problem actually is, you have to bill the primary insurance first, then submit the copay to us."
Her: "But it says non matched group number. What's wrong with the group number?"
Me: "That rejection message is a generic rejection it gives for a bunch of different reasons. This time, the reason is that the card works ONLY on copays. "
Her: "But it says non matched group number. Is the group number ok?"
Me: "The group number isn't getting to me because it's not accepting that segment of information. The reason it's not accepting that segment of information is because we don't accept that type of billing. It has to be submitted as secondary, with the primary paying. That means it will ONLY go through with an other coverage code of 2 or 8 (pharmacy codes, yay) You're using a coverage code of 3, we don't accept that."
Her: "But why is the group number wrong? I put it in just like the card said."
Me: **sighs** "I understand. Most likely, there's nothing wrong with the group number you're submitting. I do know for SURE that it won't go through because of the type of billing. So just bill the primary insurance and then bill us the copay, and it will go through. Let's break it down: did the primary insurance pay for the medication?"
Her: "She said to use this card instead."
Me: "They need to be billed together. You need to bill the primary insurance first and bill us the copay."
Her: "But that has nothing to do with the group number!"
Me: "I understand that. The rejection message is wrong. Just completely ignore it. The reason it's rejecting is because you HAVE to submit they primary insurance's copay for the card to pay. You're indicating by your codes that the primary insurance exists, and they are not paying. Is that correct?"
Her: "I haven't billed to the primary."
Me: "Ok, so bill the primary. If they pay for it, bill us the copay. If they do not, you will need to resolve the problem with them becfore you bill us."
Her: **getting frustrated** "It says group number...." **she mumbled and put me on hold**
Me: **waits, sighing**
Another pharmacist gets on. A little easier to understand.
Him: "I understand there's some problem with the group number? Could you verify that number for me, please?"
**explodes, but maintains my customer service voice**
Me: "Gladly. However, so you are aware, there's nothing wrong with the group number. That's not why it's rejecting. Regardless, the group number is XXXX-XXXX."
Him: "That's strange, that's exactly what we have in there."
Me: **sighs** "Again, that's not why it's rejecting. It's because..."
We basically rinse and repeat the EXACT same conversation I just had with his coworker. We get absolutely nowhere. He keeps insisting the rejection says group number.
Me: "Ok, again, the group number isn't wrong. It's fine. Just try this, ok? If it doesn't work, we can go back to discussing the group number. Bill the primary. When it pays, bill us the copay with a coverage code of 2 or 8. Just try it."
Him: **grumbles** "That's got nothing to do with the group number, but whatever, if it gets us closer to figuring this thing out..."
He puts me on hold. 2 minutes later, guess what I see? A freaking paid claim. Between the insurance and us, the patient's copay was $17 bucks. If they hadn't billed the primary insurance first, the patient's copay would have been about $1400.
Morons! Gah!
Basic needed info:
I got a pharmacy support call on one of our discount cards. Basically, she was submitting a claim to us for reimbursement, and it was being rejected. The reason why is because the card is designed as an insurance copay assistance card ONLY: that means, the card will ONLY pay on the claim if they include information about the primary insurance and that they paid on the medication, too.
The reason for it is that the medication is astronomically expensive. There's seperate programs for when the patient doesn't have insurance, so when they do have insurance, we give them this card. We made that rule about only paying on copays so pharmacists don't process it wrong and charge the patient $1,000-2,000 by mistake.
It's a good system. However, our computers give a generic rejection message because the program isn't intelligent enough to know why certain things don't match.
Her: "I'm getting a non-matched group number rejection message, could you help me with that?"
Me: "Certainly." *gets info*
-Sometimes the group doesn't match. Usually it does. What it REALLY means is there's no program that matches what the pharmacy is submitting... because they're not following the program rules, not because they're using the wrong group number.
Me: "Ok, looks like what the problem actually is, you have to bill the primary insurance first, then submit the copay to us."
Her: "But it says non matched group number. What's wrong with the group number?"
Me: "That rejection message is a generic rejection it gives for a bunch of different reasons. This time, the reason is that the card works ONLY on copays. "
Her: "But it says non matched group number. Is the group number ok?"
Me: "The group number isn't getting to me because it's not accepting that segment of information. The reason it's not accepting that segment of information is because we don't accept that type of billing. It has to be submitted as secondary, with the primary paying. That means it will ONLY go through with an other coverage code of 2 or 8 (pharmacy codes, yay) You're using a coverage code of 3, we don't accept that."
Her: "But why is the group number wrong? I put it in just like the card said."
Me: **sighs** "I understand. Most likely, there's nothing wrong with the group number you're submitting. I do know for SURE that it won't go through because of the type of billing. So just bill the primary insurance and then bill us the copay, and it will go through. Let's break it down: did the primary insurance pay for the medication?"
Her: "She said to use this card instead."
Me: "They need to be billed together. You need to bill the primary insurance first and bill us the copay."
Her: "But that has nothing to do with the group number!"
Me: "I understand that. The rejection message is wrong. Just completely ignore it. The reason it's rejecting is because you HAVE to submit they primary insurance's copay for the card to pay. You're indicating by your codes that the primary insurance exists, and they are not paying. Is that correct?"
Her: "I haven't billed to the primary."
Me: "Ok, so bill the primary. If they pay for it, bill us the copay. If they do not, you will need to resolve the problem with them becfore you bill us."
Her: **getting frustrated** "It says group number...." **she mumbled and put me on hold**
Me: **waits, sighing**
Another pharmacist gets on. A little easier to understand.
Him: "I understand there's some problem with the group number? Could you verify that number for me, please?"
**explodes, but maintains my customer service voice**
Me: "Gladly. However, so you are aware, there's nothing wrong with the group number. That's not why it's rejecting. Regardless, the group number is XXXX-XXXX."
Him: "That's strange, that's exactly what we have in there."
Me: **sighs** "Again, that's not why it's rejecting. It's because..."
We basically rinse and repeat the EXACT same conversation I just had with his coworker. We get absolutely nowhere. He keeps insisting the rejection says group number.
Me: "Ok, again, the group number isn't wrong. It's fine. Just try this, ok? If it doesn't work, we can go back to discussing the group number. Bill the primary. When it pays, bill us the copay with a coverage code of 2 or 8. Just try it."
Him: **grumbles** "That's got nothing to do with the group number, but whatever, if it gets us closer to figuring this thing out..."
He puts me on hold. 2 minutes later, guess what I see? A freaking paid claim. Between the insurance and us, the patient's copay was $17 bucks. If they hadn't billed the primary insurance first, the patient's copay would have been about $1400.
Morons! Gah!
They get so stuck on the first thing they hear, they have to shovel EVERYTHING out of their brain related to it and start over to get rid of the idea.
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