2010.1 - Rx Hub and Patient Eligibility
*THIS LESSON CONTAINS A MEANINGFUL USE (MU) OPTIONAL MENU SET (CHOOSE 5 OF 10) - SEE FORMULARY INFORMATION
Below we will cover the new areas within SOAPware involving the addition of Eligibility and Formulary information. First, we will review the ways to retrieve eligibility followed by a detailed explanation of the different areas involved during a patient visit.
Overview of Added Features within Rx Manager
(1) The Eligibility display is located in the upper right quadrant. Each tab represents a different coverage the patient may have.
(2) Rx Formulary information is displayed in line with the prescription itself.
(3) Formulary information displayed is always related to the currently selected Eligibility tab.
(4) Eligibility information can be re-retrieved at any time by clicking the Retrieve Eligibility Info button.
Multiple Patient Matching
In general, this should be transparent to the physician. The suggested workflow is to retrieve benefit information the night before for all patients scheduled for the next day. This allows front office staff to manage any verification issues.
In the case that eligibility is not verified prior to seeing the patient, SOAPware will retrieve this information when Rx Manager is opened.
Bulk Download - Initiated through Scheduler
Within Scheduler, click on the Tools menu and select Eligibility Download.
Bulk Eligibility Retrieval Window
After choosing to download eligibility information, the above window will appear. It displays patients on the schedule for the following day. Patients displayed are color-coded as to exact match, partial match, confirmation required or no match.
Confirmation Displayed
When you perform a bulk match for eligibility, SOAPware checks to see if current prescription eligibility information exists for the active patient. If this information is not found, SOAPware will request the most up-to-date information from SureScripts automatically. In some cases, the patient demographics sent to SureScripts will result in a less-than-perfect match that will require human confirmation. There are three possible results:
Perfect Match - eligibility is displayed
Partial Match - confirmation dialog displayed (see image above)
In the event an exact match is not found, a dialog is displayed asking for additional demographic information (any entered/edited is pushed to the patients general demographics in SOAPware). At this point you can cancel, enter/edit or resubmit. In some cases, RxHub will have a match, but the demographic information is slightly different than what is in SOAPware.
For example, in the above display note the birth date is off by one day. In this case, both the SW demographics and the RxHub demographics are displayed for your confirmation. It is suggested that you accept the demographics presented by RxHub so that future matches do not result in this confirmation step. Once you have verified the information displayed, and you agree that the patient listed on the right under RxHub is the same as the patient on the left, click Confirm. If you do not believe the patients are the same, click Cancel.
No Match - error listed in the Eligibility dialog in Rx Manager
Manual Download - Single Patient Matching
You can also check for eligibility from the Rx Manager in a patient chart. To do this, click on the "Retrieve Eligibility Info" button.
NOTE: While you can retrieve eligibility information "on the spot" in this manner, it is important that we strongly advise a workflow where clinics reconcile all patients with SureScripts before the clinician sees the patient.
The Eligibility Tabs
After Checking for Eligibility (either beforehand or when opening Rx Manager), several new tabs will appear within the "Notes" section of the Rx Manager. Each tab represents different coverage plans for this patient. Depending on the particular pharmacy benefit manager, the exact data and format returned for any given coverage will vary. At a minimum, the type of benefits will be displayed, e.g. retail, PBM (i.e. mail order or both). For example, in the above screen shot, the PBMA coverage supports only mail order.
Formulary Information
*REQUIRED FOR MEANINGFUL USE (MU) OPTIONAL MENU SET (CHOOSE 5 OF 10) - FORMULARY CHECKS
Click here for Meaningful Use Criteria
(1) Displays the Formulary status for the prescription. In this case, it is On Formulary.
(2) A summary of the cost for the medication is sometimes displayed.
(3) Info as to OTC/brand and generic/prescription status.
(4) Alternative drugs supported by the selected coverage.
(5) Displays an additional window with detailed Formulary Information.
Additional Formulary Details
This window shows the detailed formulary information displayed when you select the "Coverage Details" button (#5 above).
When a Drug is Not Covered Under the Selected Coverage
(1) This drug is not covered under the selected coverage.
(2) It is available as an OTC Brand Name.
Note that, in this example, no alternatives are displayed.