By Sarah Dean, Team Lead, Net-Rx™, and Jennifer Brink, Product Lead, Net-Rx™
Some situations require a pharmacist to submit a claim that, under normal circumstances, would be rejected by the third-party payer. For example, a patient is going on a vacation and requests a three-month supply of their medication. Submitting this claim without an explanation will cause the claim to be rejected as a “refill too soon”. To prevent rejection, this claim must be submitted with a Submission Clarification Code.
Submission Clarification Codes (SCC) are added to a claim before submission (or resubmission) to provide the third-party payer with further details about the dispensing event. They are used to proactively prevent or override claim rejections.
The SCC should be entered in field 420-DK (a universal field in pharmacy software systems) under the individual claim transaction. A maximum of three codes may be submitted on an individual claim if more than one code is needed.
There are over 30 defined Submission Clarification Codes; below is a list of some of the more commonly used codes. SCCs are defined and published by the National Council for Prescription Drug Programs (NCPDP), and a complete list can be found on the External Codes List on the NCPDP member-only portal.
There are SCCs specific to long-term care (LTC) dispensing, as well as to retail and other classes of trade. The use of SCCs are especially important for pharmacies servicing LTC facilities, and play a big role in short-cycle rules and reimbursement from third-party payers.
For example, a long-term care pharmacy that bills post-consumption (billing that is performed after a drug is dispensed) may dispense the same drug to a patient multiple times in a month but only adjudicate once. The pharmacy may be entitled to the full dispense fee for each time the medication was dispensed. The use of an appropriate SCC can communicate to the third-party payer how the claim was dispensed, resulting in proper reimbursement.
At Net-Rx™, a provider of reimbursement solutions exclusively for pharmacies, we recommend pharmacies review how they are using submission clarification codes every month to ensure proper use and to correct inappropriate coding from being submitted on future fills. Submitting an incorrect SCC may cause the claim to be denied or paid incorrectly. Additionally, incorrect coding might increase the risk of an audit by third-party payers.
There are multiple reports available from Net-Rx that list claims submitted with one or more SCCs. The Claims Data Extract tool, part of Net-Rx’s advanced business analytics platform, Metric-Rx®, allows you to search your adjudicated claims data by specific criteria, such as SCC.
EditRx, Net-Rx’s enhanced claims editing service, provides reports that list claims with Submission Clarification Codes and the corresponding quantity and day supply submitted.
This information along with guidance from Net-Rx’s pharmacy reimbursement trained analysts can help keep your pharmacy be aware of and active in best practices for submitting SCCs.
This post is related to:Claims Processing & Reconciliation