Tricare, Rotateq and the Half-Payment Vaccine

A followup to my question the other day. Amazing work.

From: Dr. Graham Barden
To: SOAPM (E-mail)

Lessons learned from Tricare & Rotateq and the Half-Payment Vaccine
-A Tragedy in several parts...
-Graham Barden, Coastal Children’s Clinic, New Bern, NC

The Fix: For Rotateq, use NDC # 00006-4047-41 and Drug Pricing Composite
Modifier of “F2”

The Lesson:

In 2008, I noticed we were getting exactly on-half the expected payment
from Tricare (HealthNet, North Region) for Rotateq. Eventually we learned
the payment problem was related to the new requirement for NDC codes for
vaccines and TriCare insisting on paying “by the ml” instead of by
the vaccine. We adjusted our billing using NDC 00006-4047-31 and all was
well until this past October. Despite having what I like to think of as
a pretty tight ship, it was not until early January that we discovered
our best “poster’ had been accepting $39.24 as payment in full for
Rotateq. $78.48 is the national CMAC price.

We originally thought we had the NDC code wrong. They wanted 00006-4047-41
which was the number on the box or Rotateq. They did not want the
NDC that is actually on the package of Rotateq which ends in “01”
instead of “41”. We tried the “01” but it bounced. The “41”
is the correct number for now. We tried adding a “2” to indicate
two quantity units, but that was rejected. We called TriCare and they
told us we were supposed to just add a “P” to the NDC code to denote
“package” since we were using the “package” NDC number and they
have not yet entered the NDC from the individual dose. We did and three
weeks later discovered that instead of paying half of the Rotateq, we
did not hear anything at all - the claims disappeared. The “P” at
the end of the NDC might work on paper claims, nit electronic. We later
discovered out claims processor, PayerPath, rejected the lost claims
into a “special” bucket that we did not know about.

We finally got our excellent HealthNet Rep who went to the mat to figure
out what had happened. This has happened all over the country since
it is a function of the TriCare claims processor, PGBA, who does 90%
of the TriCare claims. Here is her report:

“On October 28, 2010, our EDI department received notice that as of
October 22, 2010 the code for “package” would be changing from
a "p" to an "F2." This was a new ANSI requirement, not TriCare. An
occasional claim had been paid correctly since October, but those have
been hand-corrected. So the fix is specific for Rotateq: Since it is a
2 ml volume vaccine, PGBA wants us to designate this CPT code 90680 as a
package by using the Drug Pricing Composite modifier “F2” to denote
“package” instead of “UN” for “unit”. The loop for the NDC
number is 2410 and in Segment CTP. For vaccines that are equal to or
less than 1 ml, use “UN”. For Rotateq, since it is a 2 ml vaccine,
use “F2”. (Rotarix is a 1 ml vaccine and would have a “UN”
modifier). Rotateq is unique - essentially all other vaccines need
to have “UN” in this field. (the other choices for the field are
“GR” and “ML”).”

We were able to find conflicting information about the use of “F2”
on the ‘My Tricare” site. No surprise since this solution took a
lot of digging. The info is cryptic:

“NDC Numbers: Loop 2410 segment LIN02= N4: LIN03= 11 digit NDC# : Segment CTP
= UN for units and F2 for package”
And can be found here:
_>_

Other listings in My Tricare had the UN and F2 reversed!

Verification of the NDC number is here:
_>_

It is possible that if you are not having trouble with Rotateq payments,
your clearinghouse vendor may be putting the F2 modifier in your claims
for you. I did learn that PayerPath could program our claims to have
a “UN” inserted in all vaccines except Rotateq - that way we would
have to manually add only the “F2” to Rotateq. Currently we have to
modify all vaccines.

I have talked with several practices who noticed problems only recently -
so trouble may be heading your way! I encourage everyone who sees TriCare
patients to look at an EOB your self and verify the payment. If it is
half the expected, you now have the fix!*

* of course, I have not yet actually SEEN a payment of the correct amount,
but they promised…

--
Chip Hart - Pediatric Solutions * Physician's Computer Company
chip @ pcc.com * Confessions of a Pediatric
800-722-7708 * Practice Management Consultant
* http://pedsource.com/chipsblog