3.16 Claim Reversals
General Policy Description
Under certain circumstances, it is necessary to reverse a claim. Reversing a claim modifies the original prescription/claim status on the patient’s medication and claims history on PharmaNet to “reversed” and results in a billing correction.
Policy regarding claims reversals
Reversing a claim modifies the original claim status on the patient’s medication and claims histories on PharmaNet to “reversed” and automatically causes a billing correction.
College of Pharmacists of B.C. (CPBC): Modifying the prescription history for a dispensed prescription on the local software is prohibited.
If an error related to DIN or PIN, drug name, strength, quantity, practitioner ID or instructions for use is identified, the provider must reverse the claim on PharmaNet, any third-party insurer system and the local system. The provider should then make the necessary corrections and transmit the corrected claim.
CPBC: The only field that may be modified without reversing the prescription is the refill authorization field.
Reasons for reversing a claim may include the following:
- The prescription was not picked up by the patient
- The prescription was dispensed, but the quantity was changed at a later date
- A data entry error was made
- A network problem was encountered, requiring the claim to be reversed and re-entered (these are called “network reversals”)
- The prescription was dispensed under the wrong PHN
- The prescription was changed/cancelled in consultation with the physician
Important: A "Reversed" status code does not necessarily mean the drug was ever prescribed for, or taken by, the patient.
CPBC: Medications not picked up by the patient must be reversed and returned to stock within 30 days of the dispensing date.
CPBC: Reversals due to billing adjustments must be made within 120 days of the dispensing date.
All prescriptions reversed on PharmaNet, except reversals using the intervention code “RE” (“Claim reversed, data entry error”), will appear on the patient’s medication history.
Providers may reverse a claim up to 120 days after the dispensing date.
CPBC: All corrections to the medication history require that the prescription(s) be reversed and re-transmitted with the correct information, using the same date as the original prescription, not the date of correction. It is imperative that patient histories show the correct medications with the correct dispensing dates.
Backdating of claims on PharmaNet is permitted only for the purpose of correcting a previously adjudicated claim, not to alter adjudication results.
For further information, refer to Potentially Fraudulent Reversals.
Billing corrections caused by reversals may affect patient deductibles.
A patient who has previously met the annual deductible may fall below the deductible due to a claim reversal. If so, the patient must pay some or all of the cost of following claims, depending on the adjudication.
|RU||Claim reversed, not called for (not picked up)|
|RE||Claim reversed, data entry error|
|RC||Prescription cancelled by physician|
|RR||Prescription refused by patient|
|NR||Non-returnable drug reimbursement|
|UB||Consulted prescriber and changed dose|
|UC||Consulted prescriber and changed instructions for use|
|UD||Consulted prescriber and changed drug|
|UE||Consulted prescriber and changed quantity.|
PharmaNet data integrity errors can require the provider or the PharmaNet Data Quality Services team to reverse a claim.
A claim on PharmaNet generates a record in the medication history and one in the claims history. If a network problem occurs, the system may complete half the process, creating a record in the claims history without a corresponding record in the medication history, or vice versa. These are referred to as “orphan” records and must be corrected so that medication histories and claims histories are complete. When an orphan record is detected, PharmaNet will send an error message to the provider.
The Patient Coordination of Benefits (PATCoB) table, a “behind-the-scenes” table on PharmaNet, is loaded with PHNs for all B.C. residents whose drug costs are covered by one of several federal government agencies or programs. If a PHN is in the PATCoB table because the patient has federal coverage, a record is created only in the medication history. This record is not considered an orphan record. Such PHNs will return an error message on the claim.
Eliminating an orphan record
To eliminate an orphan record, contact your software vendor (PSV) or the PharmaNet Help Desk.
Providers must not reverse and re-submit claims on a different date so that a patient receives PharmaCare coverage to which they were not entitled when the item was actually dispensed.
PharmaCare Audit can examine claims histories for evidence of this activity.
Occasionally, a provider may discover that a previous claim was dispensed under the wrong PHN. These cases may come to light when a patient expresses surprise at having to pay “out of pocket.”
Some local software allows the reversal and correction of wrong PHN on claims; however, you may need to contact PharmaNet Data Quality Services.
To correct a "Wrong PHN" prescription within 120 days
- Reverse the claim and re-enter it with the correct PHN as follows:
- Reverse the claim using the incorrect PHN
- Correct the PHN on your local system
- Re-send the claim to PharmaNet with the original dispensing date
- Otherwise, contact your software vendor or PharmaNet Data Quality Services for assistance in reversing the claim.
To correct a "Wrong PHN" claim after 121 days
- Contact PharmaNet Data Quality Services.
Note: These claims cannot be reversed by providers or by PharmaNet Help Desk staff.
Handling claim reversals when changing or upgrading local software
When vendors install new software or upgrade an existing product, they perform a “software conversion.” In this conversion, existing data files from the old software are transferred to the new system.
After a software conversion, claims submitted using the old software cannot be reversed with the new software.
Providers are advised to reverse claims before a software conversion—and to talk to their software vendor before the conversion to ensure time has been allowed for pre-conversion reversals.
Prior to the conversion, reverse every claim for an item that has not yet been picked up, including those you expect the patient to pick up. You will avoid problems by reversing all claims not picked up, (e.g., if a patient picking up an item presents a new insurance card or requests a different quantity of medication).
After the conversion is complete, re-submit each claim using your new software.
It is important to reverse and re-submit claims when necessary. Doing so ensures that the patient’s PharmaNet profile remains accurate, which is essential for physicians and pharmacists who use the medication history to confirm medications.