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| PLAN DESIGN |
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Under the DP/Rx TeleClairn System, Plan Design is nothing more than the benefit manager or administrator outlining how a particular group should be processed and adjudicated. The TeleClaim user selects File Maintenance from the Main Menu and Plan Design from the File Maintenance Menu and the system delivers eleven pages or screens of adjudication options. In order to provide a fully robust system, there are over 140 blanks to be filled in with literally thousands of options. Then again, for most group plans, only a few dozen entries are actually required. Every entry is fully documented and the various options are listed right on the screen. After a couple of days of using Plan Design, entering the information for a new group takes roughly twenty minutes. Even less when an existing plan is changed or modified. For example, the first two screens of Plan Design deal with selecting which categories of drugs may be administered under the plan. Next to each drug classification, the operator is required to enter an "X" to exclude the drug, an "A" to require Prior Authorization or to leave the field blank if the drug is included in the plan. What about anabolic steroids? An X, an A or a blank? If you can answer that question as it refers to a specific plan, then you've qualified to be a TeleClaim Administrator. You assigned number 1003 to the salaried employees of Burk Rentals ... and, when setting up Group 1003, you entered the fact that they will follow Plan 2026. When you entered Plan Design for Plan 2026, you entered an "X" next to anabolic steroids ... and no member of Group 1003 will be entitled to receive anabolic steroids unless you go back and edit that plan. By entering information into a specific plan and assigning that plan to a specific group, the administrator has "programmed" the on-line adjudication for each and every member of that group. Let's suppose, further, that you are the administrator for Group 1003. Should the Pharmacist's dispensing fee be based on: (A) a percentage of AWP, (B) whether the drug is Brand or Generic, (1) a percentage of the ingredient cost, or (S) whatever the pharmacy submits as the dispensing fee. Depending on your selection, you'll be asked to enter supporting information, like the dollar amount of the dispensing fee for brand drugs and the dollar amount for generic drugs. You may even enter the limit that you might like to place on a pharmacy's submitted amount. Every aspect of adjudication is accounted for and every option under the direct control of the administrator. The major control items included are: • Formulary construction - inclusions and exclusions, • Limitations: Quantity, Days Supply, Providers, etc. • Deductible and Capitation specifications, • DUR functions - Refill too soon, therapeutic duplication, max/min dosage, etc. • Prior Authorization Required ("PAR") logic, • Pricing flexibility - Co-pay, dispensing fee, administrative fee, etc. After the plan has been entered, the TeleClaim System also offers an expansive array of utilities for denoting "exceptions" to the rules of adjudication outlined under the plan. In a series of menu selections under the Plan Design Menu, TeleClaim offers versatility and flexibility far beyond anything previously considered. It's true, you do want to exclude anabolic steroids - except for these three specific 12 anabolic steroids that you'd like to administer with Prior Authorization. And although you've opted to include prenatal vitamins, there are 36 specific prenatal vitamins that you would like to exclude. Only the TeleClaim System allows the administrator to quickly and easily enter Exceptions and Inclusions directly to the design for adjudication. Versatility that allows for brand drugs to be entered as generic, or certain selected maintenance drugs to be treated as non-maintenance. TeleClaim even allows you to easily enter a new drug "on the fly." No other system allows such powerful flexibility. If you're currently administering a claims processing system, either in-house or through a service bureau, you might inquire as to how long it would take to exclude all anabolic steroids under a particular plan while simultaneously including a dozen or more anabolic steroids by specific NDC numbers. Or, how long would it take to design a plan that only allowed for non-maintenance drugs while simultaneously allowing a dozen or more specific maintenance drugs to be treated as if they were non-maintenance. With TeleClaim, either of these procedures would take roughly two minutes. Then again, suppose you made some sort of mistake. Suppose you got the group number and plan number mixed up ... and loaded Plan 1003 for Group 2026, instead of Plan 2026 for Group 1003. No system is truly user friendly unless it provides a facility for trapping errors ... which is exactly why DP/Rx invented SIM/Plan. |
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