Introduction to Claims Management Tasks

To ensure you receive payment for all reimburseable dispenses, Touchstore recommends you include the following steps in your pharmacy's monthly or weekly tasks.

No.	Task Description	Completed
1	Validate & Verify This Month's Scripts
2	Manage Oustanding On Loans
3	Manage Hi Tech and Patient Care Fees
4	Manage LTI Patients
5	Claiming Stock Orders
6	Check for Scripts Previously Not Sent with Claim
7	Send Claim - First 3 Working Days of Each Month
8	Send Reclaims - First 8 Working Days of Each Month
9	Fix and Send Through Claim Exceptions Not Resent
10	Review Claims Dashboard
11	Review List of Reimbursement Items
12	Ensure All Items Processed
13	Register Phased Patients to Ensure Future Phase Payments
14	Review Vaccinations Rejects
15	Review Claim Monthly Detail
16	Review Product Substitution Potential Loss
17	Review Product Substitution Actual Loss
18	Ensure All Items Processed
19	Ensure All Exceptions Processed
20	Review Eligible Exceptons Not Processed Drill Down
21	Review Items Not Paid

Training Videos for Claims Management Tasks

Category	Description	Link
Claims Overview	Claims Overview & Claims Status Screen	Vimeo Video
Claims Validation	How to Validate Scripts	Vimeo Video
Claims Validation	How to Fix Scripts in Validation	Vimeo Video
Claims Validation	How to Manage Query Scripts in Validation	Vimeo Video
Claims Validation	How to Unvalidate a Script	Vimeo Video
Claims Verification	How to Verify Scripts	Vimeo Video
Claims Verification	How to Resolve Errors While Verifying Scripts	Vimeo Video
Claims Preparation	How to Manage Hi Tech Patient Care Fees	Vimeo Video
Claims Preparation	How to Manage Stock Orders	Vimeo Video
Send Claim	How to Send Your Claim	Vimeo Video
Reclaims	How to Fix & Resend Claim Exceptions ( Reclaims )	Vimeo Video

1. Validate & Verify This Month's Scripts

Select the Claims option under Modules

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The main Status screen will be displayed
Select the Claim Period you want to validate

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A total of all scripts that have been dispensed under each scheme will be displayed under Not Validated
Press the Not Validated tab to begin validating the scripts
Select one scheme at a time to validate
On this screen you will see a listing of all scripts for the currently selected scheme

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Check each script to ensure all items have the correct patient reference, date, scheme, doctor and product gms number.
Tick Validated for each script that you have validated.
If you want to keep a script on the Not Validated screen and return to it later, tick Query

Tip: Use the spacebar to mark scripts as validated and move to the next form

To change the patient reference quickly, select the script and press Edit Patient Ref
The existing patient reference will be displayed and you can enter in the new patient reference and press Ok

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To change the doctor quickly, select the script and press Edit GMS Doctor
The existing doctor will be displayed and you can enter in the new doctor and press Ok

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To change any other info for the script, select the script and press Edit Script. This will bring you into the script's PMR screen.

claims02 - Make the change necessary and press complete to return to the Claims screen. - Tick each script that has been validated - When you have checked and ticked the validated scripts press Apply and these scripts will move to the Validated tab. - Press the Validated tab and ensure you are still on the expected scheme - All scripts should be ticked. Press Verify for Claiming to move these scripts to Ready to Claim.

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All scripts under this scheme that you have validated and verified will now be under the Ready to Claim tab
Repeat the above steps for each scheme until all scripts are showing under ready to claim on the main Claims Screen.

2. Manage Oustanding On Loans

Go into Reports module

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Select the Loans by Prescriber

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Select the last 6 months to ensure there are no outstanding loan scripts

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Press Preview

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Request the prescription from each of these patients
Once you have received the prescription complete the On Loan prescription
Ensure you select the current claim period

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Validate and verify the prescription as normal

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3. Manage Hi Tech Scripts & Hi Tech Patient Care Fees

Open Reports in Rx 365
Select Patient Care Fee Report

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Select the current month up to which the Continuity period will run. E.g. When claiming for November dispenses, select November.
To create the Patient Care Fee Script, repeat the previous Hi Tech dispense and mark the item as not dispensed.

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Ensure the item has the correct GMS number for a patient care fee dispense.
Re-print a receipt for this Hi Tech item.
Validate the Not Dispensed in the Claims module.
Once all Hi Tech Patient Care Fees have been dispensed for the current month, we need to check previous months.
Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab

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Select Hi Tech Patient Care Fee

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Select the last 6 months under Claim Period to ensure no patient care fees are outstanding.

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If there are fees outstanding, go back into reports in Rx 365 and select the month that has outstanding patient care fees and follow the above steps again to claim for these outstanding patient care fees.

4. Manage LTI Patients

Open LTI Patient
Press F3
Go to Medical tab

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Click into Lti Conditions grid to create a assign a condition to this patient

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Select the Condition from the dropdown
If the patient has more than one LTI condition click into the grid and press down arrow.
Select any other relevant conditions

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Press Ok

5. Claiming Stock Orders

Select the Claims option under Modules

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The main summary screen will be displayed
Select the Claim Period

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Under the Stock Order Scheme at the bottom if there are items in Not Validated double click in the Not Validated box.
All patients with Stock Orders will be displayed
Search for each of these patients and ensure the following on the patients PMR.
Edit the doctor attached to the Stock Order script
Ensure either White or Pink Slip is selected under Rx Type

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Edit the patient attached to the Stock Order script
Ensure there is a Stock Order card with the doctor's GMS Number and 2 random letters.

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Once these two checks have been completed, validate the stock order script as normal and the stock order script should claim successfully.

6. Check for Scripts Previously Not Sent with Claim

Open Claims Module and select each month available in the Claims Period dropdown

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If there are any scripts in the status table double click in this field to open the script that has been left behind

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Edit this script and change the Form Date to this month's claim period

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Return to the Claims Module and open this month's claim period
The script you have just edited will be waiting in Not Validated
Validate the script to move this script to Validated
Complete the above steps for all scripts found on the status screen of each previous month.
Each month should be free of any scripts appearing in the Status screen as shown below

7. Send Claim - First 3 Working Days of Each Month

Select the Claims option under Modules

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The main summary screen will be displayed
Select the Claim Period that you want to send

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The total of all scripts for all schemes should be displayed under the Send Claim tab
Ensure the total of scripts under the Send Claim tab are correct and then press the Send Claim button
During the claim period, the Send Claim button will appear.
Once happy that all scripts are under Send Claim tab press Send Claim button.
The following screen will be displayed for you to confirm the total number of scripts under each scheme:

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Press Ok to send the claim.

The following confirmation is received from the PCRS and displayed on the screen:

File Loaded Successfully: 30000_20080400.zip:

File Size: 9501 bytes:

No Claims in the file: 1350

8. Send Reclaims - First 8 Working Days of Each Month

Select the Claims option under Modules

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The main summary screen will be displayed
Select the Claim Period

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Press the Claim Exceptions tab

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Select the scheme you want to check for claim exceptions
If you want all schemes displayed select All
Press the Check button
TouchstoreRx will check for any claim exceptions

Note: Claim exceptions can be checked for and re-claimed as many times as necessary for the first 8 working days of the month. After that, claim exceptions that have been fixed need to be sent with next month's claim.

If there are no claim exceptions the following message will appear:

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If there are claim exceptions they will appear as follows

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If there is an issue with the script (i.e patient card invalid for this script) the error will appear in the top section
If there is an issue with a specific drug on that script (i.e insufficient reason for a not dispensed drug) the error will appear in the bottom section
When you select a script in the top section the drugs attached to that script will appear in the bottom section
Select the script that you are fixing, read the error message and resolve the errors.
To edit the exception of a claim, select the script and press Edit Script
This will bring up the scripts dispense screen with limited options
To remove an item from claiming, edit the script, select the item to delete, change its scheme type to Drug Refund this will remove it from claiming.
Once you have resolved the errors, mark the scripts as fixed.
Press Re-Claim

9. Fix and Send Through Claim Exceptions Not Resent

Open Claims Module and select Claim Exceptions

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Select All under Schemes to view all exceptions
If there are claim exceptions they will appear as follows:

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If there is an issue with the script (i.e patient card invalid for this script) the error will appear in the top section.
If there is an issue with a specific drug on that script (i.e insufficient reason for a not dispensed drug) the error will appear in the bottom section
When you select a script in the top section the drugs attached to that script will appear in the bottom section
Select the script that you are fixing, read the error message and resolve the errors.

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To edit the exception of a claim, select the script and Click Edit Script. This will bring you to the script's dispense screen
Press complete once you fix the error.
Once you have resolved the errors, tick Fixed, and click Re-Claim
Claim Exceptions can be re-claimed as many times as necessary for the first 8 working days of the month. If these exceptions are older, they will send with the next full claim.
Ensure all Claim Exceptions have been fixed and moved to Ready to Claim before this task is complete.

10. Review Claims Dashboard

Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab

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Select Claims Dashboard

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Review your claim summarized.
Claims Items Number & Value
Manual Items Number & Value
Rejects Number & Value
Rejects by Group
Underpaid Items
Unpaid Phases

11. Review List of Reimbursement Items

Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab

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Select Reimbursement Items

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Review your full list of reimbursement items
Select any scheme
Search by form number
If you only want to high loss - enter loss great than a specific number
Check if PCRS paid you less quantity than you claimed for using PCRS Quantity vs Dispense Qty
Review your manual claims

12. Manage Outstanding Rejects

Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab

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Select Rejects report and select the last 6 months in Claim Period filter

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Tick Payment (Actionable) and No Payment (Actionable) in the Reject Group dropdown

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Untick All in the Reject Status dropdown, scroll to the bottom of this list and tick Reject Outstanding
Review the Error Message field on this Rejects list

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Reject Reason	Resolution for Reject Reason	Fixed
Invalid doctor number	Check the doctor number attached to this script. If the incorrect doctor number was applied, check what doctor the script was written by and apply to the reclaim/ not payable paperwork and resubmit. The hospital code 61559 only applies if item is a hospital emergency script.
Patient specific approval not in place	Approval can be confirmed through the ‘Eligibility Confirmation’ on the Pharmacy Application Suite under ‘Patient Specific Arrangements’.
Card Not Eligible on Date of Claim	Approval can be confirmed through the ‘Eligibility Confirmation’ on the Pharmacy Application Suite under ‘Patient Specific Arrangements’.
Duplicate Drug Codes entered. Please clarify items dispensed.	Check what the gms number attached to the drug that was dispensed. Use the change drug to change the drug if the incorrect drug was selected. Note on the reclaim/not payable form what was dispensed and ask that either the full cost is paid or that the drug cost only is paid if it is a multiple dispensing of the same drug. If it is not a pharmacy error and items were dispensed in line with doctor’s request complete the reject/not payable paperwork by requesting that the PCRS pay the drug cost only of items while explaining what happened, e.g. Paralief entered twice instead of one claim for 200 tablets – please pay drug cost only or items were weekly dispensed as per doctor’s request. The majority of items are dispensed on a 28-days cycle allowing for 1 additional monthly claim per 12 months, if it is a valid claim, print the patient’s 12 month history, attach to the reclaim / not payable paperwork and resubmit with explanation.
Duplicate item – Not Payable	what the gms number attached to the drug that was dispensed. If it is not a pharmacy error and items were dispensed in line with doctor’s request complete the reject/not payable paperwork by requesting that the PCRS pay the drug cost only of items while explaining what happened, e.g. Paralief entered twice instead of one claim for 200 tablets – please pay drug cost only or items were weekly dispensed as per doctor’s request. The majority of items are dispensed on a 28-days cycle allowing for 1 additional monthly claim per 12 months, if it is a valid claim, print the patient’s 12 month history, attach to the reclaim / not payable paperwork and resubmit with explanation.
Invalid Drug Code	Use PCRS website to check drug code, record it on the reclaim/not payable paperwork and resubmit.
Incomplete Claim, Eligibility of patient cannot be verified	Check patient’s file to see what number is recorded and if it is valid. If it is not valid check the PCRS website using the patient’s date of birth. If you cannot find the number, place a note in this patient’s file to obtain the correct patient’s number on their next visit to the pharmacy
Card not eligible on date of this Claim.	Check the patient’s file to see what was recorded and then check if the number was valid at the time the item was dispensed. If the card was valid note that on the reclaim/ not payable paperwork and resubmit. If the card is out of date or incorrect place a note on the patient’s file to obtain the correct current card number on the patient’s next visit.
Patient Number is Invalid or Blank	Check the patient’s file to see what was recorded and then check if the number was valid at the time the item was dispensed. If the card was valid note that on the reclaim/ not payable paperwork and resubmit. If the card is out of date or incorrect place a note on the patient’s file to obtain the correct current card number on the patient’s next visit.

Check the Rejects Summary Report to check the Value of outstanding Rejects
Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab

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Once All Rejects have been actioned you can move on to next step.

13. Register Phased Patients to Ensure Future Phase Payments

Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab

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Select Unpaid Phases
In this report you will see any dispenses that were marked as a phase but you were not paid the phase fee

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Note the Year, Month, Scheme and Form Number
Close Analysis 365 and Select Search on the bottom left corner of the PMR

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Press Advanced Search Tab
Press Dispense Script For Number
Enter in the Form Number in the search bar

Scheme Short Code + YYMM + / + Form Number

E.G GM2103/0183

14. Review Vaccinations Rejects

Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab
Select Pharmacy Vaccinations Rejected

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15. Review Claim Monthly Detail

Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab
Select Claim Monthly Detail

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Review your claim details:
Number of Rejects
Reject Value
Number of unclaimed HT Care Fees
Value of HT Care Fees
Claim Value
Percentage of Items Rejected
Percentage of Value Rejected

16. Review Product Substitution Potential Loss

Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab
Select Product Substitution Potential Loss

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Review Loss Potential

17. Review Product Substitution Actual Loss

Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab
Select Product Substitution Actual Loss

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Review actual loss

18. Ensure All Items Processed

Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab

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Select Eligible Claims Not Processed

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Select the last 6 months under Claim Period to ensure no eligible fees have not been processed.

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If you do see under one of the claim periods a script, check the scheme and claim period and go back into Rx Claims module to process the script for claiming. You may need to change the claim period to the current month.

19. Ensure All Exceptions Processed

Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab

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Select Eligible Exceptions Not Processed

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Expand to see exceptions per scheme

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Open up the Claims module to go and action these exceptions

20. Review Eligible Exceptons Not Processed Drill Down

Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab

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Select Eligible Exceptons Not Processed Drill Down

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Expand to drill down to form number

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21. Review Items Not Paid

Open Product Maint. in the modules dropdown

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Select Analysis tile

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Select Claims tab

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Select Items Not Paid

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Action any items that are marked as actionable