ODB Billing

Question 1

What’s the ODB usual dispensing fee?

Answer 1

$8.83

Question 2

What’s the difference between copay and deductible?

Answer 2

Copay=amount of rx cost that the pt must pay out of pocket

Deductible=fixed amount to be paid out of pocket before the insurance begins to cover any cost

Question 3

What is the markup that different insurances will pay?

Answer 3

8% ODB if drug cost $1000

10% for third party or out of pocket

Question 4

How to use NMS for out of province patients who don’t have OHIP?

Answer 4

If Canadian, use their province’s client ID and use a cardholder identity code like QC for Quebec, AB for Alberta etc.

Question 5

How to log and rx into NMS for Canadian residents w other approved ID

Answer 5

Use 0011984276 and cardholder identity code ONO

Question 6

How to log and rx into NMS for out of country residents w approved ID.

Answer 6

Use 0011984275 and cardholder identity code ONG

Question 7

How to log and rx into NMS for Canadian residents with no approved ID

Answer 7

Use 0011984277 and cardholder identity code ONX for Canadian residents with no approved ID if they’re unable to provide ID and prescriber has written why they need the med before they can obtain ID.

Question 8

ODB consists of which plans?

Answer 8

ODB (65+)
Home Care
Ontario Works (OW) for people/families in financial need.
Ontario Disability Support Program (ODSP) for people who have a disability and their family.
Trillium Drug Program (for high prescription costs)
OHIP+ (24 and under)

Question 9

Things to keep in mind about the ODB formulary

Answer 9

LU code must be written or typed
LU codes may have expiries and limits on quantities covered
Sometimes it may seem like a drug is covered based on amt MOHLTC pays but it’s actually EAP
Dr must fill out the EAP form

Question 10

When does ODB coverage start?

Answer 10

the 1st day of the month after turning 65

Question 11

What’s the ODB copay?

Answer 11

$6.11 for high income seniors + $100 deductible, $2 & NO deductible for low income seniors

Question 12

How can patients lower their ODB copay?

Answer 12

Must fill out and send Co-payment application for seniors form. If living w spouse, must apply as a couple. Must send notice of assessment from last tax year. Eligible if single income

Question 13

Trillium: who is eligible, how does coverage work?

Answer 13

For people spending more than 3-4% of their after tax household income on prescription drug costs. That 3-4% is their deductible and it’s paid quarterly (Aug, Nov, Jan, May 1st). They also have a $2 copay

Question 14

How to bill OHIP+

Answer 14

ERROR CODE PM-NO PRIVATE INSURANCE ATTESTATION MISSING

SPECIAL SERVICE CODE U - NO PRIVATE INSURANCE ATTESTATION

Question 15

How to bill ODB? Client ID & Carrier codes?

Answer 15

Client ID is OHIP number. Carrier code is C for ODSP, D for OW, P for Home care.

Question 16

What to do if ODB claim not going through?

Answer 16

Call Social Assistance Verification Helpline 1-888-284-3928 to verify coverage, document conversation, use ML code - good faith standard coverage established - this gives pt 1 day coverage

Question 17

What to do for ODB error code C2-SERVICE PROVIDED BEFORE EFFECTIVE DATE

Answer 17

call the Social Assistance Verification Helpline 1-888-284-3928

Question 18

What to do for ODB error code C3-COVERAGE EXPIRED BEFORE SERVICE

Answer 18

OW coverage expired and patient needs to contact their social worker

Question 19

What to do for ODB error code CJ-PATIENT NOT COVERED BY THIS PLAN

Answer 19

May be due to wrong carrier code, or call Social Assistance Verification Helpline 1-888-284-3928

Question 20

Where does the LU code go under for the SDM Delta system?

Answer 20

Under Med Reason

Question 21

How to bill Trillium if patient doesn’t have private insurance?

Answer 21

Bill TDP directly, patient pays until their deductible is reached then $2 copay per rx

Question 22

How to bill Trillium if patient has private insurance?

Answer 22

Bill private plan first, then patient must pay and submit receipt to trillium.
Once trillium deductible is met, trillium becomes first payer, pt must tell us when this is, or just see if it goes through.
When trillium deductible resets (Aug, Nov, Jan, May 1st) must switch back to private insurance as first payer.

Question 23

when will ODB say refill too soon, ways around this?

Answer 23

if >10 days early

can override if vacation supply, lost med, or dose change

Question 24

when can ODB claims be reversed electronically?

Answer 24

if the claim is <7 days old

otherwise the claim must be reversed manually by filling out a form and mailing it in

Question 25

How to bill ODB claims exceeding $9999.99

Answer 25

Call ODB, they’ll tell u to divide the rx into 2 or more claims and use an error code like MM-REPLACEMENT CLAIM, DRUG COST ONLY or MP-VALID CLAIM VALUE $1000 TO $9999.99. Waive dispensing fee on all claims except the first.

Question 26

ODB frequency of dispensing limits.

Answer 26

first fill 30 day trial
max qty 100 days
trillium end of period limits (error message DZ-DAYS SUPPLY LIMITED DUE TO BENEFIT YR END MAX DAYS SUPPLY ALLOWED __)
chronic meds list - ODB will pay max 5 dispensing fees per 365 day period (error message 87-EXCEEDS MAX # OF PROF. FEES FOR THIS DRUG)
compliance packaging (2 fees per 28 days, use intervention code UN: ASSESSED PATIENT, THERAPY IS APPROPRIATE) must put in BEFORE the claim is submitted, can’t be put in afterwards

Question 27

what are the allergen form and nutrition forms used for?

Answer 27

special authorization allergen form must be filled out by Dr and pharmacy to authorize reimbursement of allergen extract products
nutrition form must be filled out by doctor and pharmacist to authorize nutritional products what are the sole source of nutrition with criteria eg. oropharyngeal disorder, maldigestion disorder, chemically defined diet, etc. Valid for 1 year.

Question 28

How can a patient get a brand name drug covered?

Answer 28

patient must have tried 2 lower cost interchangeable products (or 1 if there’s only 1 available). The Canada Vigilance Reporting Form must be filled out for each by the prescriber, and pharmacy must fax the form to Health Canada’s Vigilance program at 1-888-678-6789.
the rx must have ‘no sub’ on it and when processing, choose prescriber, med reason 901, check off ‘send product selection’

Question 29

How many test strips will ODB cover per 365 days?

Answer 29

3000 if on insulin
400 if meds have higher risk of hypoglycemia
200 if meds have low risk of hypoglycemia or using lifestyle changes to manage

Question 30

What intervention codes can be used when filling test strips and ODB sends the error code OC-QUANTITY REDUCTION REQUIRED or LO-BENEFIT MAX EXCEEDED REMAINING 0 UNTIL MTH/YR

Answer 30

May occur if pt hasn’t filled insulin or high risk med through ODB in last 6 mths, use intervention code NF-OVERRIDE - QTY APPROPRIATE
Or if there’s an acute illness, infection, DDI, gestational diabetes, occupational hazard, can use intervention code MG - OVERRIDE - CLINICAL REASONS but prescriber must indicate the reason and recommended testing frequency

Question 31

How can ODB patients get a vacation supply covered?

Answer 31

Patient must fill out vacation form (indicating dates, location, med qty, pt signature, date) or provide copy of travel insurance.
If they have less than 30 day supply on hand, they can get 2 x 100 days supply covered, bill the second with MV - VACATION SUPPLY intervention code
If they have more than 30 day supply on hand, only 100 day supply will be covered
For OW max 35 days supply
For Trillium can’t request 2nd 100 day supply between Feb1-July31, even if they pay and submit it will not be reimbursed.

Question 32

What kinds of compounds are ODB covered?

Answer 32

using listed solid oral dosage forms to create suspensions eg nitrofur
injections
dermatologic preps containing no other active substances other than those listed (eg. hydrocortisone, menthol)
topical nitrogen mustard preparations
topical preps consisting on sal.acid, sulfur or tar in petrolatum jelly or lanolin
opthalmic solutions containing certain antibiotics

Question 33

What kinds of compounds are NOT ODB covered?

Answer 33

compounds equivalent to a manufactured product (even if on backorder)
2 creams mixed together

Question 34

Who can get aerochambers ODB covered? How to bill?

Answer 34

OHIP+ eligible patients under 12 can get 1 aerochamber covered per 365 days. Bill as a regular rx using PIN numbers found online

Question 35

What professional services are ODB patients eligible for and how to bill?

Answer 35

ODB patients are eligible for Naloxone, Medscheck, PO, Flu shots, smoking cessation is covered- intervention code PS - PROFESSIONAL SERVICE

Question 36

Things to keep in mind when billing naloxone kits

Answer 36

can give 1 or 2 kits, bill as 1 transaction unless injectable and inhaler
use the patient HC# or patient name Harm Reduction and ID 8999999991 and pharmacist as prescriber
there are different PINS to use depending on which kit(s)

Question 37

What are the professional service fees for Medschecks?

Answer 37

Annual ($60), Follow-up($25), Diabetes($75), Diabetes Follow-up($25), Medscheck at Home ($150). Can bill home or diabetic MC if had annual before, otherwise 1 MC per 365 days

Question 38

What professional services are non-ODB patients eligible for and how to bill?

Answer 38

For non-ODB patients, Naloxone kits, Medschecks, Flu shots are covered, use S at the beginning of the healthcard number, and intervention codes PS: PROFESSIONAL SERVICES and ML: GOOD FAITH STANDARD COVERAGE ESTABLISHED

Question 39

What’s the Clozapine special drug program?

Answer 39

There’s 3 different brand specific clozapine registries. They’re non-interchangeable as they’re used to track AEs. Hospitals prescribe and dispense, but can sometimes be delegated to community pharmacy by providing a supply for compliance packaging for example.

Question 40

What is the Tuberculosis program?

Answer 40

TB meds provided by public health dept free of charge @ clinic/hospital, board of health staff RN, or pharmacy. Only 1st line drugs covered, 2nd line if resistant and prescribed by TB specialist.