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Submission Clarification Codes Decoded

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. 

CODE

DEFINITION

03

Vacation Supply: the pharmacist is indicating the cardholder has requested a vacation supply of the medication

04

Lost Prescription: the pharmacist is indicating the cardholder has requested a replacement of medication that has been lost

05

Therapy Change: the pharmacist is indicating the physician has determined a change in therapy was required

07

Medically Necessary: the pharmacist is indicating that this medication has been determined by the physician to be medically necessary

08

Process compound for approved ingredients

12

DME Replacement Indicator

13

Payer-Recognized Emergency/Disaster Assistance Request: the pharmacist is indicating that an override is needed base on an emergency/disaster situation recognized by the payer

19

Med A Split Billing

20

340B: the pharmacist is indicating that the product being billed was purchased pursuant to rights available under Section 340B of the Public Health Act of 1992

21

LTC Dispensing: 14 days or less NOT applicable due to CMS exclusion, manufacturer packaging, or special dispensing methodology. Medication quantities are dispensed as billed

22

LTC Dispensing: 7 days

23

LTC Dispensing: 4 days

24

LTC Dispensing: 3 days

25

LTC Dispensing: 2 days

26

LTC Dispensing: 1 day

34

LTC Dispensing: 14 days

35

LTC Dispensing: 8-14 day dispensing not listed above

36

LTC Dispensing: Dispensed outside of short cycle. Claim was originally submitted to a payer other than Medicare Part D and was subsequently determined to be Part D

 

 

Click Here to See How Identifying Payer Messages Can Help You Comply With Transition Supply Requirements Efficiently

 

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.

 

Read more articles that cover topics such as Average Wholesale Price and pharmacy success through COVID-19.

 

REFERENCES:

https://www.computertalk.com/navigating-short-cycle-billing/

https://www.ncpdp.org/NCPDP/media/pdf/VersionDQuestions.pdf  

https://www.resdac.org/cms-data/variables/submission-clarification-code  

https://ncpdp.org/About-Us/FAQ

https://www.net-rx.com/Products/Metric-Rx/  

https://www.net-rx.com/Products/EditRx/

 

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