When you have a question about your pharmacy’s contractual relationship with or the processes required by a pharmacy benefit manager (PBM), where do you turn?
Your first instinct might be to consult your contract, but the details you’re looking for are likely in the PBM’s provider manual.
Provider manuals are documents created and distributed by PBMs that outline the regulations and requirements pharmacies must adhere to in order to remain in good standing with the PBM. These documents are extensions of PBMs’ contracts, and the requirements listed in the provider manual are binding through the PBM contract.
Each PBM produces its own provider manual and rules differ for every PBM, but most PBMs make their provider manuals available electronically through their websites.
Whether you contract individually or a pharmacy services administration organization (PSAO) contracts on your behalf, you have access to PBM provider manuals either way.
They offer detailed instructions on important topics, such as claims processing, compliance, audits and Medicare, so the next time you have a question, remember to check the provider manual.
Here are five common questions that PBM provider manuals can answer.
1. What happens if I’m audited?
Your contract with a PBM likely states that the PBM can audit your pharmacy, but details about audits can be found in the provider manual.
Reference this document for information about the reasons for audits, how you’ll be notified about an audit and types of audit activities.
The PBM provider manual also includes information about audit expenses, what types of documents you must produce and the possible penalties or results of an audit.
2. How do I properly process claims?
PBM provider manuals can answer almost all of your questions about claims processing.
Provider manuals include information about online claims submissions, claims formats, processing guidelines and reference materials, so you can ensure you’re submitting the claim properly.
Everything you need to know to properly process claims will be in the provider manual. It’s important to follow all of the procedures laid out by PBMs in provider manuals to ensure your claims go through.
These manuals are also a great resource for questions on filling out-of-the-ordinary claims, including coordination of benefits, compounding and long term care claims.
3. What are my responsibilities as a participating pharmacy?
Provider manuals also outline specific information that you must adhere to as a participating pharmacy.
The PBM contract might stipulate that you adhere to all requirements, but the actual descriptions of the requirements will be found in the provider manual.
Consult this document for all questions on requirements. It covers everything from quality control policies and procedures to National Council for Prescription Drug Programs (NCPDP) requirements.
4. How do I contact my PBM?
Along with specific patient care procedures, provider manuals also contain general information, including how to contact your PBM if you have a question, concern or if you need to report fraud, waste or abuse.
Keep the electronic manual bookmarked on your pharmacy computer to keep this information handy, or keep a hard copy of the provider manual in your pharmacy’s records.
5. What are my requirements when it comes to generic substitution?
While it will vary from PBM to PBM what each entity’s requirements are for substituting a generic when available, most PBMs will spell out their requirements in their provider manual.
Provider manuals will also usually detail when you’re obligated to try and substitute a generic, what to do if a prescriber requests that the patient receives the brand name product, and how to properly submit a substitution.
If you want help getting the best PBM contract possible and understanding PBM contracts and provider manual requirements, check out TriNet Third Party Network by PBA Health, a pharmacy services administration organization (PSAO) that offers third party services.
