Claiming

- Claims Module Access & Overview

To look at and work with your Claims records:

• Click Modules
• Click Claims

The Claims Module screen will now open.

The Status tab will be shown by default, giving you an easy to follow list of the number of scripts under various Schemes that are in the different stages of being prepared for sending in your End of Month Claims.

After starting the system for the first time on a given day, there will be no information shown until you select a Claim Period to view information for.

You will be able to view Claims scripts for the current claims period and for any previous one you have sent through the system.

To select the Claim Period that you wish to work with:

• In the top left of the screen, click the Claim Period dropdown
• Select the Claim Period you wish to work with.

Once you choose a Claim Period, the Summary tab will populate the table view of your scripts and their status.

When opening the Claims Module again without restarting the system, the Claim Period will default to the one previously selected when you closed out of the Claims Module.

Electronic vs Manual

The system will default to looking at your Electronic Claims first, that is those claims that can be claimed electronically through your dispensary software.

The system also allows you to view and validate scripts dispensed under Manually claimed schemes e.g. Hardship, Methadone etc...

To change between viewing your Electronic scripts and your Manual scripts:

• Click the Claim Authority dropdown

Select the Claim Type you wish to work with:

• GMS (Payments) Board - EDI is for Electronic
• GMS (Payments) Board - Manual is for Manual

N.B. when opening the Claims Module, the system will always default to viewing Electronic records.

- Review Claim Status & Claim Status Letters

Select the Claims option under Modules to access the Claims Module

This will display the Claims Status Screen where we can see the following.

• The Scheme Name - the scheme the script was dispensed under
• Not Validated - Scripts that need to be checked
• Validated - Scripts that have been checked
• Ready to Claim - Scripts that are ready to be sent

Each section can be accessed by selecting the corresponding tab located above it.

Alternatively, you can double click in the not validated, validated or ready to claim section to quickly navigate to that schemes claim section

Claim Status Letters

Letter	Meaning	Description
N	Not Validated	The item is in the Not Validated tab in the Claims module, awaiting validation by the user.
V	Validated	The item is in the Validated tab in the Claims module, awaiting verification checks by the system.
E	Exceptions	The item is in the Claim Exceptions tab in the Claims module, awaiting editing/fixing by the user.
C	Ready To Claim	The item is in the Send Claim tab in the Claims module, awaiting transmission to the PCRS.
P	Paid	The item has been sent to the PCRS and has not yet received an Exception response. As such, we assume it will be paid for unless the system is told otherwise.
D	Deleted	The item has been deleted from the Claims Exceptions tab as it was rejected by the PCRS and then deleted manually by the user, presumably because they opted not to pursue a further reclaim for the item.

- Validate Scripts for Claiming

Before sending your claim, it is important that you carry out a number of different checks on the scripts and patients you will be claiming for.

To allow you to keep track of which scripts you have checked and are happy to move forward with, the system provides a Validation process to mark items as checked, i.e. Validated or to mark them as scripts to be double-checked, i.e. Query.

When dispensing and completing scripts they will begin at a status of Not Validated.

A total of all scripts that have been dispensed under each scheme will be displayed under Not Validated in the Summary screen of the Claims Module.

To begin Validating scripts:

• Click the Not Validated tab in the Claims Module screen
• In the top left corner of the screen, select the Scheme you would like to validate first or choose All to have the full list of all of your claim scripts appear.

On this screen, you will see a listing of all scripts for the currently selected scheme.

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.
• Alternatively, when the record you want to validate is highlighted, press (KEYBOARD: SPACE) and it will mark it for you. Press (KEYBOARD: SPACE) again to unmark it.
• If you want to come back to a script that isn't validated, tick Query. This script will then stay in the Not Validated section until you have marked it as Validated even if you move everything else into the next section.
• If you are happy that all listed scripts can be marked as Validated you can click the Validate All button.

All scripts under the selected scheme will move to the Validated tab.

- Quickly Edit Patient Card or Doctor

To change the patient reference quickly:

• Select the script
• Click Edit Patient Ref and the existing patient reference will be displayed
• Enter in the new patient reference and Click Ok

To change the doctor quickly:

• Select the script
• Click Edit GMS Doctor and the existing doctor will be displayed
• Enter in the new doctor and Click Ok

- Edit Other Script Information from Claims

If you need to change other script information,

• Select the script and Click Edit Script.

This option is available from both the Not Validated screen and the Validated screen.

This will take you to the dispense screen for that script.

• Edit the information
• Click re-complete to return to the claims module

- Un-Validate a Script

If you want to push a script from Validated back into Not Validated go to the Validated tab and:

• Select the script you would like to unvalidate
• Uncheck the Validated tickbox

If you would like to push all scripts under the selected scheme back into Not Validated you can click Unvalidate All.

Now when you click Apply, move to a different tab or hit Close and close out of the Claims Module, the items you have unvalidated will move from the Validated tab into the Not Validated tab and will be available to work with in that section.

N.B. By editing the script from the PMR and recompleting it will be unvalidated, meaning if it is in Validated it will move back to Not Validated. You will get a warning about this when editing the script. However, if you edit the script directly from the Validated tab it will not be unvalidated.

- Verify Scripts After Validation

Click the Validated tab and ensure you are still on the expected scheme

• All scripts should be ticked
• Click Verify for Claiming

Once you Click Verify for Claiming all scripts will be verified by Rx 365 for the selected scheme

If there are errors in any scripts that have been verified, the system will display the errors.

- Resolve Script Errors Rx 365 has Identified

When you Click Verify for Claiming all scripts will be verified by the system for the selected scheme.

If there are errors in any scripts that have been verified Rx 365 will display the following screen detailing the errors:

If the following column is ticked:

Heading	Full Heading	Description
Prescriber No:	Prescriber Number	The GMS Number is missing or invalid for the Prescriber, open the Patient maintenance screen, double click on the Prescriber's dropdown list and find the doctor in question. Enter the GMS code for the prescriber. Alternatively, if an incorrect Doctor has been selected for the script, Edit the dispense and change the GMS Doctor assigned to the script.
Product No:	Product Number	The GMS Number is missing or invalid for the Product. Edit the script highlighted and either select a different product that has a GMS code or enter a GMS code for the product.
Patient Ref:	Patient Reference	The Scheme Reference Number for the affected patient is missing or incorrect. The Patient reference (their scheme card number) is entered on the Patient maintenance screen.The PCRS online Card checker can be used to verify the patient reference or contacting the PCRS directly.
Dupl. Scheme:	Duplicate Scheme	The affected patient has more than one of the same Scheme on their Edit (F3) screen
Form Number:	Form Number	The Form Number is missing or invalid
Not Disp Reason:	Not Dispensed reason	The Not Dispensed reason is missing or invalid
Qty:	Quantity	The Dispensed Quantity is missing or invalid. Quantity needs to be non-zero unless the item is Not Dispensed and must be greater than zero
Repeat Part Error:	Repeat Part Error	The Repeats Made or the Maximum Repeats information is missing or invalid
Amount Error:	Amount Error	The Total Cost is missing or incorrect. If the Total Cost of an item is 0.00 you will see this error. Edit the script and correct the Cost Price or select another product with an amount assigned.
Extemp Item:	Extemporaneous Item	The item is marked as an Extemp Item but does not have the correct GMS Number. GMS Numbers for Extemp items must begin with 99 e.g. 99189.

Once all scripts are fixed they can be verified again by ticking the scripts and Clicking Verify for Claiming.

All scripts will now move to Send Claim tab.

Any Errors returned by the PCRS should be followed up with the PCRS

- Prepare and Send Your Claim

If you are in the Send Claim tab in the Claims module and there is no Send Claim button, please ensure you are on your Claiming PC and you are within the claims period.

You will not be able to send your Claim on any other Rx PC.

The total of all scripts for all schemes should be displayed under the Send Claim tab.

If not, follow the steps in Validate Scripts For Claiming.

Ensure the total of scripts under the Send Claim tab are correct and then Click the Send Claim button.

The following screen will be displayed for you to confirm the total number of scripts under each scheme:

Click Ok to send the claim.

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

It should look something similar to the image below.

- Managing Drugs Payment Threshold

Once the DPS threshold is reached for a patient all scripts are marked for claiming.

If a patient does not reach the DPS threshold, scripts will not be marked for claiming.

Validation happens normally for DPS.

When all scripts are Validated, the system separates Under and Over Copayment depending on whether they have reached the DPS threshold.

To be eligible for FEMPI family Over Copayment the family need to hit the 134 Cap to be added.

By Default only Over Copayment will be displayed on the Validated tab under the DPS scheme.

You can view all scripts that are under Copayment by Clicking Under Copayment.

If you wish to send any under copayment scripts in the claim you can select the script and Click Mark Can Claim.

These scripts will then move to the Over Copayment section.

Click Over Copayment to return to the over copayment scripts that will be claimed.

- Fix and Re-send Claim Exceptions ( Reclaims )

You must be on the claims machine to check and send claim exceptions

Click the Claim Exceptions tab

• Select the scheme you want to check for claim exceptions.
• If you want all schemes displayed select All.
• Click the check button and the system will check for any claim exceptions.

The system automatically checks for Claim Exceptions every time you open it on the machine that is configured for sending your End of Month Claims.

Claim Exceptions can be 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:

If there are claim exceptions they will appear as follows

• 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 Click 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, and click Re-Claim

- Claim a Continuing Care Fee for Hi-Tech Patients

As part of providing the service of dispensing High Tech drugs to the patient, pharmacies are eligible to claim a High Tech Care fee, also known as a Patient Care Fee for handling these products for patients.

Pharmacies can claim a Patient Care Fee in the following circumstances:

The same month a High Tech Drug is dispensed.

• This is claimed normally by dispensing the item and sending it in the Claim.
• This will give you the full Patient Care Fee (approx €63.52)

In the 1st month after a High Tech drug has last been dispensed and is not being dispensed this month.

• This is claimed by dispensing the drug and marking it as Not Dispensed and giving it the relevant Not Dispensed Reason.
• This will give you the full Patient Care Fee (approx €63.52)

In the 2nd month after a High Tech drug has last been dispensed and is not being dispensed this month.

• This is claimed by dispensing the drug and marking it as Not Dispensed and giving it the relevant Not Dispensed Reason.
• This will give you HALF of the Patient Care Fee (approx €31.76)

In the 3rd month after a High Tech drug has last been dispensed and is not being dispensed this month.

• This is claimed by dispensing the drug and marking it as Not Dispensed and giving it the relevant Not Dispensed Reason.
• This will give you HALF of the Patient Care Fee (approx €31.76)

It may also be necessary for you to amend the GMS Number against your dispense to a GMS Number beginning with 88xxx.

Please check with the HSE/PCRS on this if you are unsure what GMS Number should be placed against the dispense in order to correctly claim the Patient Care Fee for the item in question.

Applying the Non-Dispensed

Select the patient's record as normal and select the last Hi-Tec dispense for the patient

• Repeat the Dispense
• Click Not Dispensed or press (KEYBOARD: ALT + T)
• Enter a Not Dispensed reason

• Edit the GMS No., replace with "88999".

If there is more than one item dispensed, replace the GMS No. for each item

• Complete the dispense as normal.

In the Claims module, Validate and Verify the dispense as normal

- Claiming Stock Orders

To claim for Stock Orders correctly in the system the following 3 things need to be true:

• Dispenses are attached to a Patient file that has the Doctor in question set as their Prescribing Doctor AND their GMS Doctor
• The Doctor in question is set up with the correct RX TYPE - the screenshot below
  • Pink Slip For NON-DISPENSING (swabs, test strips etc...) choose Rx Type 2 Pink Slip
  • White Slip For DISPENSING OF DRUGS choose Rx Type 1 White Slip
• The Stock Order scheme Card No. in Edit (F3) is set to the correct value

The Card No. for a Stock Order scheme needs to be in the format of a GMS Card No. e.g. 7 Digits and a Letter "1234567A".

In the the system, this Card No. needs to contain the Professional's 5-Digit GMS number at the beginning followed by two digits and a letter.

For example, a doctor with a GMS Number of 71502 should have a Stock Order Card No. of 7150299A. 99A can be any sequence of two digits followed by a letter.

- Preview and Print Functions

If you are looking to get a summarized view of your claim records you can apply a filter to your current claims for the selected month.

The system will allow you to filter by the below options under the preview button on the top right of the claim screen

If you are in the status tab this buttons will not work as there is no data to summarize.

You will need to be in one of the tabs below.

• Not Validated
• Validated

The claim exceptions tab and Send claim section will only show a full preview and will not have any filter icons for printing.

Once you have selected Preview/Print the below screen will appear giving you further filter options:

• Marked Query: This will exclude any records that have been marked as Query.
• Marked Validate: This will exclude any records that have been marked as Validated.
• Not Ticked: This will exclude any records that have not been ticked.

Once you are happy with your selection Click Ok.

You will then receive a print out in the below format.

- Filter Options (Form Search)

To filter your Not Validated, Validated and Claimed sections in the system there is a Search button at the top right which will filter by form number.

The format of what needs to be entered in order to trigger the search is the last 4 digits of your form number i.e. 0001, 0002, 0003 etc

- Final File

To download the Final File,

• From the PMR click Modules and select Claims
• Click on the Claim Exceptions tab
• Click the Check button

The system will check if a Final File is available and, if it is, will begin to download the Final file from the PCRS.

N.B. The Final File is normally only available around the 20th of each month but this date can vary. If you have queries on the availability of the file, please contact HSE PCRS for more information.

Once complete, the scripts marked as paid in the Final file will be marked as Paid on the Claimed tab

- Phasing Fees

When handling patients in Community or Nursing Home care, these dispenses are quite often phased out in blisters and provided to the patient / carer / home over a number of weeks. However you may not be approved for reimbursement of Phasing Fees in which case you are not eligible to claim for them.

If you are handling Ad Hoc dispenses in the system and are not eligible to claim for Phasing Fees, simply uncheck the Phased Box. If you are eligible, tick the Phased Box and proceed as normal. A fee will be claimed from the HSE PCRS for the phasing of that item.

For MDS dispenses, you can configure the Dosage System to include or exclude the Phasing Fee.

You can do this by changing the Auto Phase setting.

• Turning this ON will phase the records and claim a Phasing Fee.
• Turning this OFF will not phase the records and will not claim a Phasing Fee.