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2 Contents Introduction. 3 OutcomesMTM Participation.. 3 User Access to Protected Health Information (PHI) 3 Participation from Various Settings..3 Retail 3 LTC/Assisted Living 3 Ambulatory Care Physician Clinic 4 Acute Care 4 Use of Third Parties 4 MTM Center Pharmacist and Personnel Responsibilities.. 4 Pharmacist 4 Technician/Pharmacy Intern or Student 5 Pharmacy Administrator 5 General 6 Cognitive Impairment Determinations & Authorized 6 Returned Mail 7 Patient Opt-Out Procedures 7 Patient Health Plan Complaints 7 Data Retention 7 General Billing Information... 8 for Billable Services 8 Comprehensive Medication Reviews 9 Needs Medication Reconciliation 10 Prescriber Consultations 11 Patient Adherence Consultations 14 Patient Education and Monitoring 17 Refusals and Unable to Reach After 3 Attempts 19 No Intervention Needed 20 Auditing and Monitoring.. 20 Quality Assurance 20 Claim Status Categories 21 Fraud, Waste and Abuse 21 Resolving QA Issues 21 Corrective Action 21 Compliance and Regulation 22 Applicable Laws and Regulations 22 Kansas Medicaid Immigration Reform and Control Requirements 23 Appendix A. Glossary of Terms.23 Page 2 of 29 Questions? Call

3 Introduction These policies and procedures outline requirements for providing and documenting MTM services in OutcomesMTM programs. If an MTM Center or MTM Center personnel is in violation of an OutcomesMTM policy, OutcomesMTM will take corrective action, including, but not limited to; corrective outreach and monitoring, removing Connect Platform access, or terminating the MTM Center s network participation agreement. MTM Providers, or those seeking to become providers, in the OutcomesMTM Network can access Technical Specialists via phone and for assistance during business hours. Business hours are 7 AM to 7 PM Central Time, Monday through Friday Telephone support is available at support is available at info@outcomesmtm.com. This document includes information, concepts and intellectual property that is not to be duplicated, used, or disclosed in-whole or in-part for any purpose other than by contracted entities in the OutcomesMTM Network in the provision of covered services for OutcomesMTM eligible patients. OutcomesMTM Participation Pharmacies and other entities seeking to become authorized MTM Providers in the OutcomesMTM Network must first complete a network participation agreement available at outcomesmtm.com. All MTM Center personnel are required to individually create an account and pass the OutcomesMTM online training. After contract execution and successful completion of training, MTM Providers will use the Connect Platform to access MTM opportunities for OutcomesMTM eligible patients and submit required documentation for reimbursement. Licensed pharmacists employed by a pharmacy or other approved MTM Center are approved MTM Providers in the OutcomesMTM program. Nurses, prescribers and other non-pharmacy professionals are not authorized to deliver MTM services unless approved by the health plan. User Access to Protected Health Information (PHI) An administrator shall be designated by the MTM Center to provide oversight of user roles and access. It is the responsibility of the administrator for each MTM Center to monitor and approve/remove user access to PHI maintained on the OutcomesMTM platform at least monthly. In instances where an administrator is not established for an MTM Center, OutcomesMTM will request 3rd-party employment verification to approve user access. The MTM Center is still responsible for monitoring and removing user access to PHI. Only pharmacists approved by the MTM Center shall perform, document and bill for MTM services in OutcomesMTM programs. User access to PHI will be restricted if the user has been inactive for 60 days. Participation from Various Settings MTM Providers employed by contracted MTM Centers may deliver MTM services to OutcomesMTM eligible patients. To access MTM Opportunities, MTM Center personnel must be granted permission to by an administrator of the MTM Center. Based on the healthcare setting some MTM services may be restricted. Retail OutcomesMTM will populate an MTM Opportunity List for the MTM Center in the Connect Platform. The MTM Opportunity List contains patients who have filled at least one medication within the past six months at the pharmacy. Pharmacists may provide and document covered services the patient may be eligible to receive by his/her health plan. LTC/Assisted Living Pharmacists located in or serving patients who reside in long-term care facilities or other types of institutional living quarters may only provide a limited menu of covered services to OutcomesMTM eligible patients. Similarly, pharmacists serving patients whose medications are administered by another healthcare professional may also only provide a limited menu of covered service to OutcomesMTM eligible patients. Page 3 of 29 Questions? Call

4 In these unique circumstances, to determine if a patient can receive a covered service, the pharmacist should first assess who is responsible for the patient s medication dosing/administration. If the patient or a family member/friend is responsible for medication dosing/administration, the patient is eligible for the standard covered services. The pharmacist may provide and document all services the patient may be eligible to receive through his/her health plan. If a facility staff member or healthcare professional is responsible for the patient s medication dosing/administration, the patient is only eligible for the Comprehensive Medication Review and Prescriber Consultations. Comprehensive Medication Reviews are not the same as a chart review and should not be delivered as such [For more information about the CMR service see Covered Services]. If a facility staff member or healthcare professional is responsible for the patient s medication dosing/administration, the patient is not eligible for Patient Adherence Consultations and Patient Education & Monitoring services. The pharmacist may not bill for these services even though the patient may be eligible to receive them through his/her health plan. Ambulatory Care Physician Clinic Pharmacists located in ambulatory care physician clinics may provide MTM services to OutcomesMTM eligible patients who visit the clinic. For those seeking to become authorized MTM Providers please contact OutcomesMTM for contract information. Pharmacists cannot bill for an MTM service in the Connect platform if they have billed for that same cognitive service elsewhere, including but not limited to: CPT codes (e.g. MTM services) HCPCS codes (e.g. Transitional Care Management, Medicare Wellness Visits, Diabetes Self- Management Training/Education) Incident to billing Specific contracts with private payers Acute Care Pharmacists located in acute care facilities are not permitted to provide MTM services to OutcomesMTM eligible patients while inpatient. Patients in these facilities are already receiving direct care from a healthcare professional and MTM billing would be considered double billing for services. Use of Third Parties To maintain the integrity and quality of services provided through our programs, outsourcing or subcontracting MTM opportunities by an MTM Center to an offsite, third-party pharmacist or consulting firm is not permitted. This policy applies to any dispensing pharmacy location, as well as any user interested in documenting and billing for MTM services on the OutcomesMTM platform. Failure to adhere to this policy may result in removal from the OutcomesMTM Network. MTM Center Pharmacist and Personnel Responsibilities Unless otherwise permitted by a health plan, only the following roles are permitted to view and/or complete MTM opportunities for OutcomesMTM eligible patients. Each role is unique and is only to be used by those individuals who meet the requirements and are able to fulfill the responsibilities listed below. Pharmacist Pharmacists accessing MTM opportunities via the Connect Platform must maintain a license in good standing with the board of pharmacy. All active licenses are to be maintained in the pharmacist s OutcomesMTM profile. OutcomesMTM requires each pharmacist to abide by the laws pertaining to MTM in the state in which he/she practices pharmacy. For more information pertaining to state laws, please contact the respective state board of pharmacy. If a pharmacist is found to be inadequately licensed, his/her claims will not be compensated and participation may be terminated from the program. Pharmacists accessing MTM opportunities via the Connect Platform must have successfully completed the OutcomesMTM online training. Additionally, he/she must have been granted permission to accessing patient health Page 4 of 29 Questions? Call

5 information via an MTM Center administrator. Pharmacists are liable for all services and claims in which his/her name is associated. As such, pharmacists should never share account log in credentials with any other individual or pharmacy personnel. Each MTM claim submitted for payment shall be delivered by an approved MTM Provider. Claims should not be submitted by a pharmacist who was not involved in the MTM service delivery. Pharmacy students may provide MTM services under the direct supervision of an approved MTM Provider at the MTM Center. The pharmacist shall use his/her discretion in the level of oversight required based on the student s professional training. The pharmacist acknowledges and agrees that all clinical and therapeutic decisions relating to the provision of MTM shall be the exclusive responsibility/liability of the approved MTM Provider supervising the MTM service delivery by the student. Pharmacists may allow a technician or pharmacy student to document a service in the Connect Platform on his/her behalf. The pharmacist acknowledges and agrees that the documentation and billing responsibility/liability remains with the pharmacist. Technician/Pharmacy Intern or Student The use of technicians and students in a supporting role is encouraged to maximize the time spent with the patient/patient representative for the pharmacist. Each technician or student providing support for MTM services is required to have his/her own user account for the Connect Platform and must successfully complete the OutcomesMTM online training. He/she will document all claims under his or her account and will select the pharmacist affiliated with the MTM Center who supervised/provided the service. The below rules apply to the role of the technician/student in supporting MTM services. a. A technician/student is permitted to: i. Identify patients eligible for MTM services ii. Alert pharmacists to billable MTM services iii. Schedule MTM appointments for a pharmacist iv. Collect a complete medication list from the patient prior to a CMR v. Document MTM services provided by a pharmacist vi. Distribute and monitor communications (e.g. Standard Patient Takeaway, prescriber fax forms) vii. Monitor claim status and advise pharmacist on documentation changes needed for claims in Review & Resubmit status Pharmacy students can provide MTM services under the supervision of an OutcomesMTM-trained, licensed pharmacist physically onsite at the MTM Center (each MTM claim will need to have the supervising pharmacist selected within claim submission). The pharmacist shall use their discretion in the level of oversight required based on the student s professional training. The pharmacist acknowledges and agrees that all clinical and therapeutic decisions relating to the provision of MTM shall be the exclusive responsibility/liability of the pharmacist. Pharmacy Administrator An administrator shall be designated by the MTM Center to provide oversight of user roles and access. The administrator is responsible for granting and removing user access to PHI for new or terminated employees. An administrator should only grant access to the Connect Platform after the requesting user s employment and role have been verified. Pharmacy interns should always be assigned the Tech/Pharm Intern or Student role. The Pharmacist role is only for those individuals that have obtained pharmacist licensure by the state Board of Pharmacy. The administrator acknowledges and agrees that government mandated oversight is being performed on all users in which he/she grants access to the Connect Platform. For more information, see Applicable Laws and Regulations. Page 5 of 29 Questions? Call

6 General The following documentation requirements apply to all OutcomesMTM covered services. See Documentation Requirements for Billable Services on page six for delivery and documentation requirements for each MTM opportunity. Each claim submitted via the Connect Platform is coded via a similar format. o Indication for service (reason) o Service provided (action) o Outcome of service (result) o Additional information as required by the claim type Only one MTM claim may be submitted per intervention. o For example, if a pharmacist initiates a medication change due to suboptimal therapy a Suboptimal Drug Discontinued Therapy claim and a Needs Drug Therapy - Initiated New Therapy claim for the medication change cannot be submitted. Instead, only the Suboptimal Drug - Changed Drug claim should be submitted for the intervention. A severity level is required to be included on every MTM claim documented in the Connect Platform. OutcomesMTM applies the healthcare cost that was avoided to the severity level selected. For more information about severity levels, see page 26 Appendix A. o OutcomesMTM pre-assigns severity levels for: Comprehensive Medication Reviews Patient Education and Monitoring claims pertaining to new or changed prescription therapy Patient Consultations affiliated with the Adherence Monitoring Program Patient/prescriber refusals Prescriber Consultations pertaining to cost efficacy All Unable to Reach After 3 Attempts claims All MTM claims resulting from a TIP o The following claim types, if initiated by the pharmacist, require the pharmacist to document a severity level and provide patient-specific information to support the severity level selected. Prescriber Consultations (except those pertaining to cost efficacy) Patient Adherence Consultations Patient Education & Monitoring claims pertaining to OTC therapy Each MTM claim is required to be submitted within 7 days of the date the outcome of the service was determined; however, OutcomesMTM encourages MTM Providers to complete documentation and billing immediately upon completion of the service to minimize the risk of the patient no longer being eligible at the time of billing. All claims submitted are subject to quality assurance review. For more information, see Auditing and Monitoring. Cognitive Impairment Determinations & Authorized Representatives In the event the MTM Provider determines the patient is cognitively impaired and unable to participate in a CMR, we recommend the MTM Provider reach out to the patient s caregiver, prescriber or other legally authorized personal representative to take part in the CMR. This applies to patients in any setting and is not limited to patients in long term care (LTC). If a legally authorized personal representative participates in the CMR on behalf of the patient, it is the responsibility of the MTM Provider to verify and document the personal representative's legal authority to act, such as a duly executed power of attorney or medical power of attorney, in compliance with state laws and regulations. The verification of such documentation shall be available upon request. Page 6 of 29 Questions? Call

7 If a patient is determined to be cognitively impaired, MTM Providers are required to document the rationale for the cognitive impairment determination in the Connect Platform. Options for documentation include the following: Cognitive impairment: YES and unable to participate o Brief Interview for Mental Status (BIMS) score o Mini-mental state examination (MMSE) score <19 o Cognitive impairment noted in patient s chart o Confirmed status with family member/caregiver o Confirmed status with healthcare staff If the MTM Provider documents the patient is the recipient of the CMR in the Connect Platform, it is assumed the patient has no cognitive impairment or is mildly cognitively impaired but was determined to be interviewable by the MTM Provider. In general, the patient is interviewable if the patient demonstrates no short term or long term memory deficits, as determined by the MTM Provider. The MTM Provider may choose, but is not required, to utilize one of the available mental status assessments, such as the Brief Interview for Mental Status (BIMS) or Mini-mental state examination (MMSE) assessments, to make this determination. The below assessment scores indicate the patient has no cognitive impairment or is mildly cognitively impaired but may be interviewable. o Brief Interview for Mental Status (BIMS) score 13 o Brief Interview for Mental Status (BIMS) score 8-12 Mild cognitive impairment, but based on the MTM Provider s professional judgment the patient is able to manage their medications and is interviewable o Mini-mental state examination (MMSE) score 24 o Mini-mental state examination (MMSE) score Mild cognitive impairment, but based on the MTM Provider s professional judgment the patient is able to manage their medications and is interviewable Returned Mail OutcomesMTM requires the CMR standard Patient Takeaway to be delivered to the patient within 7 days of the date the CMR was completed. If the pharmacy delivers the Patient Takeaway via mail and the mail is returned, contact the patient to verify/update address. The returned standard Patient Takeaway must be provided to the patient as soon as possible to ensure compliance with CMS requirements. If the patient s address cannot be confirmed, the Patient Takeaway must be provided to the patient in person the next time the patient visits the pharmacy. If the Patient Takeaway cannot be provided to the patient, you must notify OutcomesMTM. To avoid returned mail, OutcomesMTM encourages pharmacists to verify the address during the CMR service. Patient Opt-Out Procedures An MTM-eligible patient may refuse or decline individual services without having to disenroll from the MTM program. However, if an MTM-eligible patient requests to disenroll from the MTM program entirely, please contact OutcomesMTM at , so OutcomesMTM may notify the health plan of the disenrollment. Patient Health Plan Complaints If an MTM-eligible patient has a complaint about their health plan, please direct the patient to call the health plan customer service phone number on the back of the prescription drug card or call OutcomesMTM at to obtain the appropriate phone number to provide to the patient. Data Retention Any back-up documentation utilized during the provision of service is required to be retained on-site for 10 years, or as otherwise required by OutcomesMTM. Back-up documentation may include prescriber notes, CMR Worksheets, Encounter Worksheets, power of attorney forms, or anything not captured in the Connect Platform which would support the claim result. Page 7 of 29 Questions? Call

8 General Billing Information The following billing requirements apply to all OutcomesMTM covered services. See for Billable Services on page six for delivery and documentation requirements for each MTM opportunity. OutcomesMTM does not guarantee payment for services provided when the patient was not eligible. Each MTM claim is required to meet the minimum documentation and billing requirements outlined in this guide and the Connect Platform to be eligible for payment. Claims missing required information or that need clarification will be placed in Review & Resubmit status, if appropriate. OutcomesMTM shall compensate the MTM Center for the provision of MTM services in accordance with the rates adjudicated within the Connect Platform upon claim approval. Under no circumstances shall OutcomesMTM be required to compensate MTM Center for provision of MTM to any person who is not an OutcomesMTM eligible patient. When the change in therapy is verified in the patient s prescription claims data provided by the health plan, a validation payment may be made. The MTM claim s validation status is determined 120 days following the MTM service date. Validation payments may vary by health plan and are applicable for select plans. Only medications that are processed via the patient s prescription drug plan will be eligible for validation. Claims may only be billed for services in which a pharmacist intervention was made. If the pharmacist did not perform an intervention that resulted in a medication change a claim cannot be billed. For example, if a medication was discontinued prior to a pharmacist recommendation being made, no intervention was performed by the pharmacist and a claim should not be billed, or in the instance of a TIP, the TIP should be documented as No Intervention Needed. for Billable Services The billable services and documentation requirements listed below contain the interventions payable within OutcomesMTM programs. Covered services vary by health plan and are patient-specific. To see which services an OutcomesMTM eligible patient may receive, view the patient s profile in the Connect Platform. COMPREHENSIVE MEDICATION REVIEWS A Comprehensive Medication Review (CMR) is an interactive, person-to-person consultation to complete a review of the patient s current medications (including prescriptions, over-the-counter (OTC) medications, herbal therapies and dietary supplements) performed in real-time by a pharmacist; a summary of the review is required to be provided to the patient in the CMS standardized format. On average, CMRs provided in the OutcomesMTM program take 30 minutes to complete. All CMRs scheduled in the Connect Platform should be scheduled for the time confirmed by both the patient and pharmacist. CMRs that are scheduled without the patient s knowledge are subject to cancellation. Although not required, OutcomesMTM encourages pharmacists to provide the patient s primary care provider with a copy of the Patient Takeaway to maintain continuity of care. Page 8 of 29 Questions? Call

9 Needs CMR Complex Drug Therapy (100) Comprehensive Medication Review (200) CMR Drug Therapy Problems Identified (300) OR Needs CMR Complex Drug Therapy (100) Comprehensive Medication Review (200) CMR No Drug Therapy Problems Identified (301) 1. Select the appropriate method of delivery face-to-face, phone or telehealth a. If phone is selected, a prior authorization code may be required (to obtain a prior authorization code, contact OutcomesMTM in advance of CMR delivery.) b. In instances where a HIPAA-compliant video-conferencing technology is utilized to provide the CMR, please document the method of delivery as telehealth 2. Review and update the patient s Health Profile to include the following information: a. Current Conditions b. Drug Allergies & Side Effects (include drug name and reaction) 3. Review and update the patient s Medication List to include all current prescription and non-prescription medications. Medication(s) must include: a. Medication name and strength b. Directions for use (quantity, form, route and frequency, in patientdirected language) c. Related Condition d. Prescriber (for OTC medications use self ) 4. Document each actionable item identified during the CMR on the Medication Action Plan (MAP) a. Include the following for each issue, in patient-directed language: i. Description of the item ii. What the patient should do b. Arrange the actionable items/topics discussed in order of importance, with the most important item(s) listed first 5. Date CMR was completed 6. Recipient of the CMR a. If someone other than the patient, document the following: i. Role of the CMR recipient (e.g., legally authorized representative) ii. iii. iv. Name of the CMR recipient Patient s cognitive impairment status (yes/no). To determine cognitive impairment status, utilize facility personnel, family members and any established documentation to support the decision, where applicable. If the patient was determined to be cognitively impaired, document how the determination was made 7. Pharmacist s availability for questions 8. Where the Patient Takeaway should be sent a. If the patient was the recipient of the CMR service, the Patient Takeaway must be delivered to the patient. b. If the takeaway should be sent to an address other than the patient s address, document the recipient s name, address, city, state and ZIP code. c. If the patient is cognitively impaired, the takeaway should be sent to the patient s legally authorized representative. Document the legally authorized representative s name, address, city, state and ZIP code. 9. Select the language for the Patient Takeaway template (all information entered by the user will appear in the language entered by the user) a. If the default English template is selected, all free text fields must be completed in English. b. If the Spanish template is selected, all free text fields must be completed in Spanish. i. The free text fields on the Medication Profile and Medication Action Plan will not auto-translate. 10. Date of Patient Takeaway was delivery 11. Attest to reviewing the patient s drug allergies & side effects, medications and MAP and providing the CMR recipient with the exact Patient Takeaway generated by the system (no substitutions) 12. Create the Patient Takeaway, print and deliver to the patient (or the recipient of the CMR) within 7 days of the date the CMR was completed 13. Submit the CMR claim Page 9 of 29 Questions? Call

10 NEEDS MEDICATION RECONCILIATON A claim may be documented with the Needs Medication Reconciliation reason code when a patient has been recently discharged from the hospital and is an appropriate candidate for a medication reconciliation. A consultation with the patient/patient representative is necessary to reconcile all medications. Additionally, a consultation with a prescriber or discharge facility may be necessary to obtain a discharge medication list. Medication reconciliation (MedRec) is the process of comparing a patient s pre-admission medication list to the discharge medication list to prevent or identify drug therapy problems. The MedRec service helps ensure any changes made to the patient s medication list are intentional based on the patient s post-discharge care plan. Obtain discharge medication list from an appropriate source (e.g. patient, caregiver or health system). Compare the discharge medication list with the patient s medications prior to hospitalization to determine which medications should be stopped, started or continued. Consult the appropriate physicians when necessary. Deliver Prescriber Summary to patient s Primary Care Physician (PCP). Deliver Patient Summary to patient or caregiver. Counsel on which medications to start, stop or continue. Deliver Pharmacy Summary to applicable dispensing pharmacies (optional). Needs Medication Reconciliation (102) Medication Reconciliation (202) Completed Medication Reconciliation (302) 1. Date of discharge 2. Discharge facility 3. Review and update the patient s current conditions and drug allergies/side effects 4. Reconcile the medications a. Obtain the discharge medication list b. Select where the discharge medication list was obtained c. Indicate if each medication should be stopped, started, or continued 5. Attest that all stopped medication prescriptions have been deactivated in the dispensing system 6. Indicate what was discussed with the patient/patient representative (select all that apply) 7. Completion date of the Medication Reconciliation (Encounter Date) 8. Method of delivery 9. Recipient of the Medication Reconciliation (MedRec) a. If someone other than the patient, document the following: i. Role of the MedRec recipient (e.g., legally authorized representative) ii. iii. Name of the MedRec recipient Patient s cognitive impairment status (yes/no). To determine cognitive impairment status, utilize facility personnel, family members and any established documentation to support the decision, where applicable. 10. Primary Care Physician (PCP) Information a. Does the patient have a PCP? i. If yes, enter the PCP name, phone number and fax number b. Is there an appointment with the PCP following discharge? i. If yes, enter the date of the scheduled appointment (optional) 11. Review, print and deliver the Patient Summary generated by the OutcomesMTM platform (no substitutions) a. Document the date the summary was delivered to the patient b. Select the recipient of the summary c. Indicate the name and address of the recipient of the summary d. Enter additional notes to be include in the summary (optional) 12. Review, print and deliver the PCP Summary generated by the OutcomesMTM platform (no substitutions) a. Document the date the summary was delivered to the PCP b. Indicate the name, phone number and fax number of the PCP c. Enter additional notes to be included in the summary (optional) 13. Review and deliver the Pharmacy Summary generated by the OutcomesMTM platform (optional) a. Document the date the summary was delivered to the pharmacy b. Name, address, phone number and fax number of the pharmacy c. Enter additional notes to be included in the summary (optional) Page 10 of 29 Questions? Call

11 PRESCRIBER CONSULTATIONS The following billable services require a consultation with the prescriber and communication with the patient regarding any changes in medications. Cost Effective Alternative A claim may be documented with the Cost Effective Alternative reason code when a patient is identified as using a higher cost drug product when there may be a cost-effective alternative available. A consultation with the patient/patient representative and the prescriber is necessary to complete the change in medication regimen. TIP Note: If the patient was already prescribed a more cost-effective alternative prior to TIP initiation or the patient is not an appropriate candidate for the Cost-effective Alternative TIP, the TIP should be submitted as No Intervention Needed. Cost Effective Alternative (105) Initiated Cost Effective Drug (305) Cost Effective Alternative (105) Discontinued Therapy (335) 1. Confirmation the prescriber & patient agreed to the cost-effective alternative 2. Confirmation the patient has a new, valid prescription for the cost-effective alternative 3. Confirmation the prescription for the higher cost medication has been deactivated/discontinued/closed 4. Date the outcome was determined 5. Initial prescription including quantity and days supply last prescribed 6. New prescription therapy including the quantity and days supply of the new prescription NOTE: Dispensing an AB-rated generic equivalent when state law does not require a prescriber consultation does not constitute a payable claim. 1. Confirmation the prescriber agreed the patient no longer needs the high cost medication 2. Confirmation the prescription for the higher cost medication has been deactivated/discontinued/closed 3. Date the outcome was determined 4. Initial prescription including quantity and days supply last prescribed 5. Patient-specific details about the steps that were taken to complete the intervention Needs Drug Therapy A claim may be documented with the Needs Drug Therapy reason code when a medication is needed for an untreated indication. A consultation with the patient/patient representative and the prescriber is necessary to initiate the change in medication regimen following a pharmacist recommendation. TIP Note: Claims from TIPs initiating a medication the patient is already prescribed, but not actively taking, are payable if the patient obtains the medication. If a patient is not an appropriate candidate for the Needs Drug Therapy TIP, the TIP should be submitted as No Intervention Needed. Needs Drug Therapy (120) Initiated New Therapy (330) 2. New prescription therapy 3. Severity level and patient-specific information that supports the severity level selected OR Patient-specific details about the steps that were taken to complete the intervention Needs Immunization A claim may be documented with the Needs Immunization reason code when an immunization is indicated for the patient. A consultation with the patient/patient representative following the pharmacist s recommendation is necessary to successfully administer the immunization. In some instances, a patient may elect to receive the immunization from a physician office. This is acceptable as long as the immunization administration date is verified and documented. Please note this intervention is documented as a prescriber consultation even when a pharmacy has a standing protocol for the administration of immunizations. Some health plans require a successful CMR claim within the last 12 months as a pre-requisite for a patient to be eligible for an immunization MTM service. TIP Note: If a patient has already received the recommended immunization or is not an ideal candidate for the immunization, the Needs Immunization TIP should be submitted as No Intervention Needed. Page 11 of 29 Questions? Call

12 Needs Immunization (121) Immunization Administered (331) 1. Date immunization was administered 2. Date the outcome was determined a. This date cannot be greater than 30 days from the date the immunization was administered 3. Immunization prescription information Unnecessary Prescription Therapy A claim may be documented with the Unnecessary Prescription reason code when a patient is prescribed a medication that is not indicated. A consultation with the patient/patient representative and the prescriber is necessary to initiate the discontinuation of a drug therapy following a pharmacist recommendation. Unnecessary Prescription Therapy (125) Discontinued Therapy (335) 2. Unnecessary prescription including quantity and days supply last prescribed 3. Severity level and patient-specific information that supports the severity level selected OR Patient-specific details about the steps that were taken to complete the intervention Suboptimal Drug A claim may be documented with the Suboptimal Drug reason code when a patient is prescribed a medication that is a suboptimal selection for the patient. A consultation with the patient/patient representative and the prescriber is necessary to initiate the discontinuation of a drug therapy or change a drug therapy following a pharmacist recommendation. TIP Note: If a patient s medication was already discontinued or changed prior to TIP initiation or the patient is not an appropriate candidate for the Suboptimal Drug Selection TIP, the TIP should be submitted as No Intervention Needed. Suboptimal Drug (130) Discontinued Therapy (335) Suboptimal Drug (130) Changed Drug (340) 2. Suboptimal prescription including quantity and days supply last prescribed 3. Severity level and patient-specific information that supports the severity level selected OR Patientspecific details about the steps that were taken to complete the intervention 2. Suboptimal prescription including quantity and days supply last prescribed 3. New prescription therapy including the quantity and days supply of the new prescription 4. Severity level and patient-specific information that supports the severity level selected OR Patientspecific details about the steps that were taken to complete the intervention Dose Too Low A claim may be documented with the Dose Too Low reason code when a patient is prescribed a medication at a dose insufficient to be effective. A consultation with the patient/patient representative and the prescriber is necessary to initiate the change in dose following a pharmacist recommendation. Dose Too Low (135) Increased Dose (345) 2. Initial prescription including quantity and days supply last prescribed 3. New prescription therapy including the quantity and days supply of the new prescription 4. Severity level and patient-specific information that supports the severity level selected OR Patientspecific details about the steps that were taken to complete the intervention Adverse Drug Reaction A claim may be documented with the Adverse Drug Reaction reason code when a patient is prescribed a medication with adverse reaction risk significant enough to render a drug therapy unsafe, including side effects and allergic or idiosyncratic reactions. A consultation with the patient/patient representative and the prescriber is necessary to initiate the discontinuation of drug therapy, decrease the dose or change a drug therapy following a pharmacist recommendation. Page 12 of 29 Questions? Call

13 Adverse Drug Reaction (140) Discontinued Therapy (335) Adverse Drug Reaction (140) Changed Drug (340) Adverse Drug Reaction (140) Decreased Dose (355) 2. Prescription related to the adverse drug reaction including quantity and days supply last prescribed 3. Severity level 4. Patient-specific information that supports the severity level selected 2. Prescription related to the adverse drug reaction including quantity and days supply last prescribed 3. New prescription therapy including the quantity and days supply of the new prescription 4. Severity level 5. Patient-specific information that supports the severity level selected 2. Prescription related to the adverse drug reaction including quantity and days supply last prescribed 3. New prescription therapy including the quantity and days supply of the new prescription 4. Severity level 5. Patient-specific information that supports the severity level selected Drug Interaction A claim may be documented with the Drug Interaction reason code when a patient is prescribed two or more medications with an interaction risk significant enough to render the regimen unsafe. A consultation with the patient/patient representative and the prescriber is necessary to initiate the discontinuation of drug therapy or a change in drug therapy following a pharmacist recommendation. TIP Note: If a patient already received a medication regimen adjustment prior to TIP initiation or the patient is not an appropriate candidate for the Drug Interaction TIP, the TIP should be submitted as No Intervention Needed. Drug Interaction (145) Discontinued Therapy (335) Drug Interaction (145) Changed Drug (340) Drug Interaction (125) Decreased Dose (355) 2. Prescription related to the drug interaction including quantity and days supply last prescribed 3. Severity level and patient-specific information that supports the severity level selected OR Patient-specific details about the steps that were taken to complete the intervention 2. Prescription related to the drug interaction including quantity and days supply last prescribed 3. New prescription therapy including the quantity and days supply of the new prescription 4. Severity level and patient-specific information that supports the severity level selected OR Patient-specific details about the steps that were taken to complete the intervention 2. Prescription related to the drug interaction including quantity and days supply last prescribed 3. New prescription therapy including the quantity and days supply of the new prescription 4. Severity level and patient-specific information that supports the severity level selected OR Patient-specific details about the steps that were taken to complete the intervention Dose Too High A claim may be documented with the Dose Too High reason code when a patient is prescribed a medication at a dose too excessive to be safe. A consultation with the patient/patient representative and the prescriber is necessary to initiate the decrease in dose of the drug therapy or a change in drug therapy following a pharmacist recommendation. Dose Too High (150) Decreased Dose (355) Dose Too High (150) Changed Drug (340) 2. Initial prescription including quantity and days supply last prescribed 3. New prescription therapy including the quantity and days supply of the new prescription 4. Severity level and patient-specific information that supports the severity level selected OR Patientspecific details about the steps that were taken to complete the intervention 2. Initial prescription including quantity and days supply last prescribed 3. New prescription therapy including the quantity and days supply of the new prescription 4. Severity level and patient-specific information that supports the severity level selected OR Patientspecific details about the steps that were taken to complete the intervention Page 13 of 29 Questions? Call

14 PATIENT ADHERENCE CONSULTATIONS The following billable services require a consultation with the patient/patient representative, at a minimum, to successfully complete the intervention. Needs Medication Synchronization A claim may be documented with the Needs Medication Synchronization reason code when a patient is an appropriate candidate for having his/her medications synchronized to a common fill date. A consultation with the patient/patient representative is necessary to successfully synchronize his/her medications. Medications being synced must be dispensed by the documenting pharmacy. TIP Note: For a Needs Medication Synchronization TIP, if the patient s medications are already synchronized or the patient is not an appropriate candidate for synchronization the TIP should be submitted as No Intervention Needed. Needs Medication Synchronization (122) Medications Synchronized (332) Needs Medication Synchronization (122) Medications Synchronized (332) MEDSYNC ADVANTAGE TOOL 1. Medication synchronization date a. Select the first date all medications will be refilled together 2. Medications that will be synchronized a. At least two synced medications are required and one must be a Star medication 3. Indicate Sync by checking the box for those medications to be filled on a common date moving forward a. To add a medication from another pharmacy to the MedSync Plan obtain the patient s approval to transfer the medication and receive the new prescription 4. Indicate Don t Sync for those medications that will not be filled on a common date NOTE: The MedSync Advantage tool is only available for select health plans and is accessible for users with Internet Explorer version 9 or higher, Firefox or Chrome browsers. MANUAL MEDSYNC DOCUMENTATION 1. Date you created the medication synchronization plan (Encounter Date) 2. Medication synchronization date a. Select the first date all medications will be refilled together 3. Medications that will be synchronized a. At least two synced medications are required and one must be a Star medication 4. The quantity, days supply and fill date for the next medication fill Needs Medication Assessment A claim may be documented with the Needs Medication Assessment reason code when a patient is using a medication with a high risk for adverse events. A consultation with the patient/patient representative is necessary to complete a medication assessment that evaluates the present of an adverse event(s). TIP Note: For a Needs Medication Assessment TIP, if the patient is no longer using the targeted medication or is not an appropriate candidate the TIP should be submitted as No Intervention Needs Medication Assessment (124) Assessment completed No issues identified (324) Needs Medication Assessment (124) Assessment completed Issues identified (325) 1. Attestation that the patient was provided the education outlined in the TIP overview 2. Complete the following Yes/No questions: a. Did the patient report any adverse events? b. Is the patient s relevant disease state controlled? (i.e. INR is within goal range) 3. Date the outcome was determined 1. Attestation that the patient was provided the education outlined in the TIP overview 2. Complete the following Yes/No questions: a. Did the patient report any adverse events? b. Is the patient s relevant disease state controlled? (i.e. INR is within goal range) 3. Date the outcome was determined Page 14 of 29 Questions? Call

15 Needs Lab Monitoring or Health Test A claim may be documented with the Needs Lab Monitoring or Health Test reason code when a patient is in need of a lab or screening. A consultation with the patient/patient representative is necessary to administer the lab or screening. TIP Note: For a Needs Lab Monitoring or Health Test TIP, if the patient has already received the lab or screening or is not an appropriate candidate the TIP should be submitted as No Intervention Needed. Needs Lab Monitoring or Health Test(126) Completed Lab Monitoring or Health Test (326) 1. Date Lab/Health test administered 2. Lab/Health test value 3. Name of primary care provider 4. Date the outcome was determined Adherence - Overuse of Medication A claim may be documented with the Adherence - Overuse of Medication reason code when a patient is non-adherent due to a demonstrated overuse of a medication. Both an initial and a follow-up consultation with the patient/patient representative are necessary to alter the patient s behavior to become adherent to the therapy. Adherence Overuse of Medication (155) Altered Adherence (360) 1. Date of initial adherence consultation 2. Date of follow-up (must be at least 14 days after the initial consultation and must include refill verification) 3. Attestation that the patient reported improved adherence upon follow-up 4. Prescription information 5. Severity level 6. Patient-specific information that supports the severity level selected Adherence Underuse of Medication A claim may be documented with the Adherence Underuse of Medication reason code when a patient is non-adherent due to a demonstrated underuse (>6 days missed in a 30-day supply/>18 days missed in a 90-day supply) of a medication. Both an initial and follow-up consultation with the patient/patient representative are necessary to alter the patient s behavior to become adherent to the therapy. Adherence Underuse of Medication (160) Altered Adherence (360) 1. Date of initial adherence consultation 2. Date of follow-up (must be at least 14 days after the initial consultation and must include refill verification) 3. Attestation that the patient picked up the next refill on time (within 6 days for a 30 day dispense supply or within 18 days for a 90 day dispensed supply) a. The on-time refill must be after the date the non-adherence was identified but cannot be the same day 4. Attestation that the patient reported improved adherence upon follow-up 5. Barriers to adherence (select all that apply) 6. Solutions to identified barriers to adherence (select all that apply; at least one solution per barrier is required) 7. Prescription information 8. Severity level 9. Patient-specific information that supports the severity level selected Needs Refill A claim may be documented with the Needs Refill reason code when a patient is in need for a medication refill. A consultation with the patient/patient representative and a refilled medication are necessary to complete this service. TIP Note: If the patient is no longer taking the targeted medication, has already refilled the medication or is not an appropriate candidate for the TIP, the Needs Refill TIP should be submitted as No Intervention Needed. Page 15 of 29 Questions? Call

16 Needs Refill (163) Patient Refilled Rx (363) 1. Attestation that the medication refill occurred 2. Confirmation the patient will pick up the medication 3. Date the outcome was determined 4. Prescription information Adherence Inappropriate Admin/Technique A claim may be documented with the Adherence Inappropriate Administration/Technique reason code when a patient has demonstrated inappropriate administration technique of a drug product that has negatively affected the outcome of therapy. Both an initial and follow-up consultation with the patient/patient representative are necessary to alter the patient s behavior to become adherent to the drug therapy. Adherence Inappropriate Admin/Technique (165) Altered Administration or Technique (365) 1. Date of initial adherence consultation 2. Date of follow-up (must be at least 14 days after the initial consultation) 3. Attestation that the patient reported improved adherence upon followup 4. Prescription information 5. Severity level 6. Patient-specific information that supports the severity level selected Adherence Needs Check-in A claim may be documented with the Adherence Needs Check-in reason code when a patient may or may not be adherent to his/her medication but could benefit from additional education about the medication, potential or existing barriers to adherence and reinforcement of the importance of adherence to the medication. A consultation with the patient/patient representative is necessary to educate, assist and reinforce medication adherence. TIP Note: If the patient is no longer using the medication or a medication in the same drug class the Adherence-Needs Check-in TIP should be submitted as No Intervention Needed. Adherence Needs Check-in (171) Adherence Check-in Completed (371) 2. Barriers to adherence (select all that apply) 3. Solutions to identified barriers to adherence (select all that apply; at least one solution per barrier is required) 4. Prescription information Adherence Needs Check-in + 90-day Fill A claim may be documented with the Adherence Needs Check-in + 90-day Fill reason code when a patient may or may not be adherence to his/her medication but could benefit from a 90-day supply of the medication. A consultation with the patient/patient representative is necessary to provide additional education about the medication, assist with overcoming potential or existing adherence barriers, reinforce the importance of adherence to the medication and transition to a 90-day supply of the medication. In some instances, a consultation with the prescriber may also be necessary to obtain a prescription for a 90-day medication supply. TIP Note: If the patient is no longer using the medication or a medication in the same drug class the Adherence- Needs 90-day Fill TIP should be submitted as No Intervention Needed. Selection of result code Adherence Checkin Completed + 90-day Fill indicates the patient is agreeable to transitioning to a 90-day supply of the medication and an updated prescription has been obtained from the prescriber for a 90-day supply, where necessary. Adherence Needs Check-in + 90-day Fill (172) Adherence Check-in Completed + 90-day Fill (372) 1. Confirmation the patient agreed to the 90-day fill 2. Confirmation the patient s prescription is written to allow a 90-day fill 3. Date the outcome was determined 4. Barriers to adherence (select all that apply) 5. Solutions to identified barriers to adherence (select all that apply; at least one solution per barrier is required) 6. Prescription information Page 16 of 29 Questions? Call