DP/Rx TeleClaim System

SYSTEM OPERATOR’S GUIDE

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• Health Maintenance Organizations (HMOs)
• Preferred Provider Organizations (PPOs)
• Pharmacy Benefits Managers (PBMs)
• Administrators
• Service Bureaus
• Pharmacies - Major chains and independents

The claims come in from Pharmacys and are routed and adjudicated automatically, without any human intervention. As questions come in to the help desk about particular issues, the help desk personnel can review the claims and take appropriate action to resolve the issues. From time to time there will be manual data entry to keep the records up to date, and periodically, reports will be created for distribution to Clients.

The system mostly runs with a minimum of intervention.

Care should be exercised in staffing the positions that will support the TeleClaim environment since the members of this group will maintain close contact with the customer base as well as the DP/Rx technical group. It is desirable that there are experienced personnel with a mature attitude in problem solving at all levels.

The TeleClaim System requires one System Administrator, one (or more) System Operators and one (or more) Help Desk Operators. These may all be the same person, however at least 1 backup person should be designated and trained.

Once the staff has mastered the daily operations and cycle routines, it would be wise to initiate a cross-training program. It should be part of an on-going plan that the System Administrator and System Operator trade responsibilities once a month as soon as it is deemed appropriate.

The System Administrator should have a strong background in the pharmaceutical industry with specific experience in benefit plan design; familiarity with personal computers is desirable but not necessary. The System Administrator should spend time (as available) on a full cross-training program. This cross-training program should continue until each individual, System Administrator and System Operator, is fully capable of handling every task involved in the system, from hard copy entry to disaster recovery.

The System Operator is responsible for the Daily Operations of the Reports Module, hard copy entry of prescriptions (if any), entry of data received on diskette or email (if any), and End of Period report generation. The System Operator reports to the System Administrator and shall fulfill any additional duties as assigned. A System Operator should have two or three years of solid experience in the computer environment and the ability or potential to cross-train on the duties of the System Administrator in the event of illness, etc.

The exact number of System Operators required would depend on the volume of hard copy entries, the volume of member updates that must be entered by keyboard, and the volume of diskette entries.

Given a minimum of hard copy or diskette entries and a minimum of direct entries for new members, the system requires only one System Operator.

The Pharmacy Resolution Center Coordinator for the Help Desk will receive and direct Pharmacy inquiries. He/She should have extensive background in the pharmaceutical industry, have demonstrated computer ability somewhat higher than the average user, be trained on the use of remote access software, and be well versed in TeleClaim processing.

All calls should be recorded, logged, and the Pharmacy Resolution Center Coordinator will formulate an appropriate response. The System Administrator shall periodically inspect these logs for response fulfillment.

The network should be designed to limit access to the TeleClaim programs and directories through the use of Login Scripts and permissions. Any Network Operating System (NOS) should give the administrators/users the ability to provide it’s users certain level of access to its server’s resources. The system should be planned to suit the needs of the company using the TeleClaim system. Please note that giving permissions/access to certain areas of the server that are vital to the system operations is beyond the control of DP/Rx Corporation. It is therefore the sole responsibility of the administrator to impose these restrictions/access. In reality, you should give full access to those who need access (read/write) to the system and give read only permissions to users who are not allowed to change anything. System administrators and certain levels of management should be given administrator rights. The most common break-in in any corporation is within the users/employees in the corporation itself. For security from the Internet point of view, no public IP address should be installed on the server since the server is only used as a LAN based server. Making the file server Internet enabled (assuming no firewall is installed on your network) is prone to attacks from the public network. If you really need to Internet enable your server, you must use some kind of proxy server or firewall on your network. In this way you can protect or restrict the access to your server from the outside world. And

finally, your Network and System Administrators should know the networking and security issues that your company is facing.

The TeleClaim security system is used in addition to the network security. With it the Administrator can assign operator passwords with access to menu items as deemed necessary. Clients may also be given permission to use the system and they can be restricted to view/change their own information.

The techniques and password support provided by TeleClaim is independent of similar support provided by Local Area Network software. Your System Administrator will be provided with a master password, which will allow access to the TeleClaim security screens.

The TeIeClaim System requires that power on and power off of the system occurs in a specific order.

This guideline will give the user a view on how to re-start the system. Proper sequence should be implemented so that no files will be left open and users will not be left logged on without giving them a chance to save their work before restarting the system. And most importantly, by properly shutting down the system, you can minimize data corruption on your database. The idea of the proper system restart is to shut down the component that is interfacing users remotely. This means shutting down the Front End Processor (interfacing with Network Centers, Telecom, i.e. NDC, Envoy) first. If you are using PBM terminals (Pharmacy Terminal), that goes also the same level as the Front End Processor (FEP) restart. If a PBM terminal is using PCAnywhere (or other software for remote computing), be sure that no user is currently logged on. Most of these software programs have the capability to send a message to the remote users. You can send a short message to the remote users that you are intending to restart the system and this will give your users a chance to save their work. By shutting down the Front End Processor first, no incoming claim or request will be accepted for processing. Next to be shut down are the Adjudicator workstation and DUR (Drug Utilization Review) server. Network mappings on the server will be disconnected and no file will be left opened. If any other workstations are currently logged on to the server, these should be shutdown also. The last to be shutdown is the server itself. After shutting down all components of the system, it’s now time to restore the system. Restoring the system is just the reverse of shutting down. Wait at least 1 minute before re-starting to allow the disk drives to stop. First power on the server and wait until it is fully restored before restoring all the other computers. Restore the Adjudicator machine and DUR Server. Lastly, power on the Front End Processor and any PBM Terminals.

The TeIeClaim System has been designed to be menu-driven. The Front End and Adjudication Processors handle all the on-line claims processing on a daily basis and rarely require any operator attention.

Systems operations are generally confined to the Reports Machine Module. File maintenance, at the direction of the System Administrator, may involve adding new members, changing drug prices, loading new drug files, designing a new Plan file for new group’s adjudication, or entering paper claims into the system by keyboard.

The structured layout of the TeIeClaim Main Menu on the Reports Machine is easy to follow and self-explanatory, once the operator has been properly trained.

Upon logging in to the server, each person will be placed on the Main Menu. Some users may not have all the options below.

File Maintenance - Manually maintain Master Files

File Inquiry - Inquire Master Files

Master Listings - Produce Listings of Master Files

Claims Inquiry - Help Desk Claims Inquiry

Printing - Print spooled reports and listings

Import/Export - Import File Maintenance/Export Files

Cycle Processing - Daily/Monthly/Quarterly/Financial Cycle Processing

Offline Entry - Enter Manual Claims and Adjustments

Misc. Functions - Company Information, etc.

SimPlan - Simulate Claims for Plans

Exit - Exit TeleClaim System

For better response, especially for remote users, our current screens are TEXT based rather than GUI.

For navigation through the menus, just use the up/down arrows and press Enter to execute your choice.

There is a status bar under each menu with a further description of the choice.

Inside programs, you use the TAB key to navigate forward or backward through the fields, and press Enter

To accept the screen. Numeric fields will not accept non-numeric data, and may enter from left-to-right or right-to-left. Decimal points should be used in $ fields. Numeric fields that go from left-to-right will right-justify after exiting the field. Most screens ask for confirmation, usually Y/N for yes/no, or F/B for forward/backward.

Critical fields are checked for content, and errors are flagged in red. You cannot accept a screen until all errors are corrected. Screens also give the operator an opportunity to cancel any changes.

While you can use upper or lower case, most data is changed to upper case automatically (for sorting reasons).

The network automatically handles the daily exchange of files between the Adjudicator and the Server.

The Help Desk will mostly be using the Claims Inquiry functions to answer questions from Pharmacys.

There may be File Maintenance, both manual and imported.

There may be manual claims and adjustments to be done.

These can be done by one person, or several people. The manual file maintenance and claims entry will normally be entered from paper forms filled out in advance.

For imported maintenance, the files to be imported must be in the \workfile directory under the proper name.

Drugs=drugs

Doctors=doctor

Formulary=form

Member eligibility=member

Pharmacy=pharmacy

Groups=group

When doing File Maintenance, you must observe the hierarchy structure. The Maintenance Menu is setup in the proper order. First, you must have a Client, then you can add Plans, Groups, Members, etc. For additions to the system, you should be working from papers that have been filled in previously. If you encounter errors, the papers should be returned to the source with notes relating to the errors. For Import maintenance, each run will produce a report with all errors listed in detail, to be returned to the source of the data for correction.

Exported files will be placed in the \export directory and will have an extension of sdf. They will be ASCII fixed length records. There are file layouts in the \layouts directory for each file.

Daily cycle is run each midnight and requires that the reports machine be put into the daily cycle before midnight. This allows for the saving of current transactions to the server.

Monthly cycle processing takes place on a monthly calendar basis. After midnight on the 1^st of a new month, the transaction files for that month are archived. After this occurs, the monthly cycle should be run to produce the monthly reports.

The financial cycle may be run at anytime, with possible different cycles per Client. Checks for Pharmacys and Members can be cut at any time, for certain periods, and as often as needed.

Quarterly cycle is run after each quarter, after running the month end cycle. This will produce quarterly reports and rebate data files if applicable.

Financial cycles may produce checks for Pharmacys and Members if your system is set up to do this. The check program is interactive. If there are problems with the printer or the paper, you can restart and reprint until all the checks are produced.

As reports are created, they are placed in the \printdir directory. They can be printed via the Printing option on the Main Menu. As Windows and Novell do not offer printing control features, we have written our own. The Program lists all print jobs with their date of creation, a description of the report, size in bytes, number of pages (optional) and report frequency. The reports are shown in different colors depending on the frequency. Reports can be selected and printed at will. Please note that a new report created with the same name will overwrite an existing report, so they should be printed in a timely fashion. Monthly reports will remain until the next monthly cycle, as will financial reports.

We suggest archiving these reports, either on disk or tape. At DP/Rx we made a directory \printdir\previous, and we archive all monthly and financial reports into zip files. Example: 2000jan.zip, etc. This way we can easily retrieve any report. Then it can be moved to \printdir and printed through the menu.

Note: the reports are all 132 columns, and will not print properly unless the printer is set to condensed print mode. Our program will do this automatically as necessary for all printers that follow the HP protocols. Other printers may need to be setup to do this. Consult the printer manual if necessary.

Backup

Each installation is responsible for backing-up their data. Using a proper tape drive and software will accomplish this task easily and automatically. We make recommendations in our Hardware document for the type of tape drive and software to purchase for your system. It is up to the Client to install these and to schedule proper back-ups.

1. Use the Daily tapes writing the date on the label (i.e. MONDAY 3/7).
2. Continue using the DAILY tapes and save the FRIDAY tape for each week.
3. On the last day of the month use the correct MONTHLY TAPE. After the back up, place the MONTHLY tape aside for SAFE keeping. Follow the tape manufacturer’s instructions in order to protect the contents of the tape from accidental destruction. If the last day of the month falls on a weekend, place the MONTHLY tape in the tape drive on the Friday before the last day of the month instead of the Friday tape. It is good practice to keep most of the tapes in a safe deposit box, away from your installation.

The three most critical components of effective Disaster Recovery are: availability of redundant hardware equipment, comprehensive file management archive policies and the strength of internal cross-training strategies to insure availability of qualified personnel.

Once a disaster occurs, these three components will quickly translate into the three questions that will ultimately determine how quickly the system is back in operation:

• How soon can we get the hardware to replace the equipment that has failed?
• Are all the files properly archived from the last tape back up to enable us to restore the system?
• How soon will a trained technician/operator arrive who is sufficiently familiar with both the hardware and the software to rebuild the system or to affect necessary repairs/replacements?

TeleClaim customers own their own hardware and are responsible for obtaining their own hardware maintenance contracts. This includes the communication equipment such as the P.A.D. and other modems.

Given that all three of these resources are on-site, "down-time" due to a disaster should be minimal.

A System disaster may be defined as having four specific levels:

• Level I: Failure of an easily replaceable device.
• Level II: Power Outage.
• Level III: Hard Disk, Controller or Motherboard failure.
• Level IV: Catastrophic fire, flood, etc.

Disaster recovery involves the management of resource components with varying degrees of importance. Hardware recovery is the least critical component of disaster recovery; it can be purchased and it can be insured. Trained personnel and system software/data files are significantly more important.

We have designed the TeleClaim System to speedily overcome most hardware problems.

The most common failures (Level I) will be the easiest to deal with: monitor, modem, keyboard, power supply, etc. The solution is no more complicated than rapid replacement. We suggest that there should be at least one duplicate unit on-site to cover immediate replacement of the defective unit.

Various communications devices (DigiBoard) and tape back-up devices should also be stored on-site as feasible.

The next most common problem (Level II) involves power fluctuation or outage. The best defense against Level II electrical power problems is the installation of a "dedicated" electrical power line for all system equipment and an Uninterruptable Power Supply (UPS) and the placement of the least number of critical units on the same circuit.

The dedicated line ensures minimum interference from other electrical devices on the premises. The UPS is a battery-powered unit that maintains electrical power to the system for a limited time after a power outage has occurred.

In the event of an extended outage the battery powered UPS may not be adequate to sustain electrical power to the system until power restoration from the public utility. If this is not acceptable, there are UPS devices that are, in fact, power generators that run on gasoline/diesel.

Level III disasters are slightly more difficult to manage. A Level III disaster would consist of: a hard disk failure, a hard disk controller failure, or a motherboard failure.

Hard Drive failures constitute a more likely Level III disaster. The TeleClaim System deals with this eventuality by offering redundant system processors, disk mirroring or RAID 5 configurations that use "hot swapping" and "automatic re-build" to prevent system halt due to hard disk failures.

Computer motherboards rarely fail. In a friendly environment the motherboards should last a decade or more.

Given that the Communications Processor/DigiBoard is the most difficult unit to configure properly, serious consideration should be given to on-site storage of an additional "redundant’ Communications Processor.

Should you experience a Level IV catastrophe and you have adhered to off-site storage of your backup tapes (or are fortunate enough to still have readable tapes); DP/Rx in California can assist you in getting back on line.

In any case, the selected and documented method of disaster recovery should be tested periodically to insure that when catastrophe hits the plan does not prove to be another catastrophe.

Disaster/recovery plans depend heavily on the manner a business is operated and the level of business tolerance to partial services. It is, therefore, difficult if not impossible to develop a plan that will cover all critical points for everybody. Each DP/Rx product user should develop their own plans and feel free to contact DP/Rx for assistance.

YOUR DATA IS POSSIBLY YOUR MOST VALUABLE ASSET.

At least half of all file maintenance procedures scheduled by the System Administrator should include strategy to prepare for eventual disaster. At a minimum, the most recent tape back-ups of program files, master files and transaction files should be stored in a fireproof safe.

If the entire TeIeClaim System is destroyed tomorrow it can be economically replaced in a matter of hours. Not only can it be quickly purchased; it can also be insured so as to provide minimum financial hardship. With a responsible level of in-house cross training, the personnel will be there to run the restored system.

Redundant off-site storage approach may seem cumbersome, but it actually could involve nothing more than dropping three or four tape cassettes in a small carrying case in the backseat of a car.

DP/Rx has personnel available to receive support calls from 7:00 a.m. to 5:00 p.m. West Coast Time. Support requests outside these hours are handled on an individual basis.

Two pager numbers are available for EMERGENCY support only.

The pager numbers are: (818) 228-1345 & (818) 228-1346. A page should be preceded by a brief voice message describing the problem left on the Headquarters main phone, (818) 865-0099. In this manner DP/Rx will know who is placing the request and the phone number at which this individual can be reached.

A third shift operator having a procedural difficulty does not constitute a DP/Rx emergency. In-house technical support should address that category of assistance. Hardware malfunctions are the responsibility of the hardware owner and a maintenance contract should be in force with a local service organization.

An example of an EMERGENCY situation demanding a page to DP/Rx would be as follows:

• Operator is notified by the switch that there is no response at the facility. The adjudication has stopped.
• Check the Adjudicator for an error message on the screen or see if the time of day has stopped.
• Check the F.E.P. to see if the time of day has stopped or if the ports are hung and not responding.
• If none of the above proved true, the operator resets the P.A. D. and checks for correct operation.
• Next the F.E.P. should be re-booted.

• If the problem persists, the Adjudicator should be re-booted.
• If a hardware failure is detected, it should be corrected after the system is powered down.

If the problem still persists, and hardware failure has been ruled out, NOW would be an appropriate time to call DP/Rx and leave a message and then use one of the pager numbers.

Leave a phone number, especially during off-hours, and leave at least the name of one additional person to reach if the primary person who placed the call is unavailable.

This document is not for general publication. The recipient is strictly prohibited from reproducing or distributing the contents without prior written consent of DP/Rx Corp, 28047 Dorothy Drive, Suite 200, Agoura Hills, CA 91301. Phone (818) 865-0099.

Send mail to contact_us@dprx.com with questions or comments about this web site.

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