Claims and End of Month Routine Guide

CLAIMS and END OF MONTH ROUTINE

Steps 1 to 5 must be done on last day of month (even if it is a Sunday or a Bank Holiday):

1. Validation of all electronically-claimed prescriptions should be done on a daily basis throughout the month using e-claims. Validation of all non-electronically claimed prescriptions (EU/Dental/Hardship/Methadone) should be done on a weekly basis throughout the month using. Ensure all schemes have been fully validated to date at this point.

2. At start of day, commence filing and sorting of prescriptions into individual bundles. Ensure that validation is complete and thorough - no query prescriptions, no missing forms [e.g. Hospital Emergency where prescription copy not present - send off signed Claim Form anyway], no GMS prescriptions where more than one GM/GR number is used per form, etc. Ensure that all prescriptions for E.U. Scheme and Dental Scheme have the item codes for each drug written in on the script. Ensure that all DPS prescriptions for unlicensed medicines (e.g. 77751 codes) have a copy of the invoice attached and cost price for the drug written on the Claim Form. All of this should have been done as prescriptions were being dispensed, and should have been double-checked when prescriptions were validated, therefore in theory none of this should have to be done today.

3. Ensure that all High Tech patients are being claimed for correctly. If there are any high-tech patients who have not been dispensed their medication this month but who were dispensed it at some stage in one of the three preceding months, you are entitled to claim a High Tech Patient Care Fee for the current month. Print off a High Tech Report for this month and the preceding 3 months (i.e. if this is the April claim then the date range should be from 1^st January to 30^th April), mark off those patients for whom you are eligible to claim a fee, then go into those patients’ files and enter a High Tech Patient Care Fee. Ensure you print off a receipt for each of these, write a valid reason for claiming the fee on the receipt, add it to the High-Tech bundle, then go into the claim file and validate the dispensing.

4. Count each bundle of forms and write the total on a note on each bundle for comparison with figures at step 6.

5. Continue dispensing throughout the day, verifying as you are going along and updating the totals for each bundle. Also modify any High Tech patients who might turn up on the last day.

Steps 6 onwards must be done on the first business day (not Saturday, Sunday or Bank Hol. Monday) of the month:

6. Print off the Claims Statistics Report or equivalent and check that the total number of forms for each scheme on the Claims Statistics Report tallies with the counts done in step 4. Sort out any discrepancy now (missing scripts, etc). If there is still something unresolved, sort it out immediately. Only when all figures are tallying, move on to the next step.

7. As a FINAL check before transmitting the claim, go into E-Claims or equivalent and:

(a) Confirm that there are no queried items remaining.
(b) Check for any rejected claims which can be resubmitted. This includes any prescriptions still on the system which had errors during a previous claims transmission and still have not been corrected. See if any of these can be corrected now prior to transmission. If not, make sure to actively pursue these in the coming days.
(c) Check if there are any non-claimed scripts on the system. This includes any prescriptions from the current claim, which were deleted from the claim, but not deleted from the patient history. These will not be transmitted in the claim so make sure that they should in fact be listed here. If they are here by mistake, hit the Delete button on the keyboard to delete them from this list i.e. to reinstate them in the claim.
(d) All prescriptions claims should have the relevant valid patient number (GMS, DPS, LTI, HAA, HT, etc) as well as the Item Code for each drug. Furthermore, GMS, GMS Repeat, Hospital Emergency, EU & Dental Schemes must have a valid Doctor’s GMS number. Correct any outstanding errors immediately.

8. You are now ready to transmit the Electronic Claim. When the system has dialled into the GMS/PCRS and transmitted the claim a notification window will tell you that the claim has been sent successfully.

9. Print off any reports required for claim validation once you receive the Claim summary books from PCRS.

10. Prepare all paperwork in neat bundles and post off to the PCRS. Remember you have 3 working days to transmit the electronic claim and 5 days to post the paperwork to be eligible for early payment.

11. On the the 3^rd day of the month go into E-Claims and Download Exceptions. Fix any errors and resend the claim to avoid unnecessary paper rejects.

12. On the 5^th day of the month, go into E-Claims and Download Exceptions again. There should now be no further errors. If there are, continue fixing, resending, and rechecking until all sorted.

13. Finally, on the 24^th day of the month, go into E-Claims and Download Final Exceptions.

Download:

• Printable ICPhA End of Month Guide (PDF)
• Printable ICPhA Claims Analysis Sheet (PDF)
• Scheme Administration Guide 2012/13 (PDF)
• Methadone Payment Calculator (XLS)
• Nurse and Midwife Prescribing (PDF)
• Reimbursement Resources (ICPhA)
• LTI Core Lists (ICPhA)
• HSE Scheme Forms (ICPhA)