Effective March 23, 2019, this exclusion filter allows Covered Entities (CEs) to exclude retail prescriptions from 340B eligibility based on Patient Residence Codes, which are listed in the image below.
Patient Residence Codes identify where a patient lives (i.e., Home, Assisted Living Facility, Hospice, etc.) and are required by Centers of Medicare & Medicaid Services (CMS) for all Medicare claims. When a pharmacy transmits Patient Residence Code when billed, 340B Architect receives the code via the pharmacy’s switch data. The system will then continue to test additional criteria to accurately disqualify prescriptions according to 340B and CMS guidelines.
How It Works
In DATA REVIEW>Utilization Manager, we’ve added three columns:
- Pt Res Code - Patient Residence Code. The standard CMS code that identifies non- qualifying residences from switch data.
- Pt Res Code Desc - Patient Residence Code Description. The details that describes non- qualifying residences.
- Pt Res Code Exc - Patient Residence Code Exclusion. This test column indicates whether a prescription’s PRC has been excluded.
- Y=Excluded (not eligible for 340B)
- N=Not excluded (eligible to qualify for 340B)
To manage Patient Residence Codes:
- Go to DATA REVIEW>Qualification Filters.
- In FILTER TYPE, select Excluded by Patient Residence option.
- Select Refresh Filters.
- Select the appropriate code you want to exclude.
5. Click Add Selected Filters. The current date will be the effective date.
NOTE: Only Hospital users can exclude PRC codes in Qualification Filters.
Q & A
Q. Can you explain why you would need to exclude these types of patients?
A. Regarding Patient Residence Codes, these have been made available for CEs as an option to exclude retail prescriptions. CEs have the capability to exclude those scripts from qualifying for 340B by excluding by Patient Residence Codes.
For example, a CE may have a prescriber who works in the hospital but also treats patients in a Group Home or for Hospice. They may want to exclude all prescriptions with these codes from qualifying for 340B.
Q. Can you see the Patient Residence Code in the Utilization Manager for each script? Is this similar to excluding by location?
A. Yes, if a Patient Residence Code is included as part of the script that was processed by the retail pharmacy, it will appear in Utilization Manager. Not every script will have a Patient Residence Code. Whether a Patient Residence Code appears in Utilization Manager depends on the information that the retail pharmacy sends. Currently, only Relay Health and Emdeon are sending Patient Residence Codes to 340B Architect. QS/1 is in the process of updating their data to include the Patient Residence Code in their data.
Q. If there were two different nursing homes, and one was eligible and the other is not, would this feature be able to distinguish between the two facilities or would you have to filter out both?
A. No, the system would not be able to distinguish between the two. Nursing Home was a bad example to use as it is not a PRC option.
Q. How can I set the effective date for the residence code exclusion?
A. The date that a user adds the Excluded Patient Residence Code filter is the effective date. However, users can backdate the effective date by editing the filter.
Q. Are there any Patient Residence Codes that you recommend that we exclude?
A. That is for each CE to evaluate and decide based the type of patient residences that are in proximity to its geographical area.
Q. The Codes are standard, but how do they originate? From Contract Pharmacies or prescriptions?
A. The Patient Residence Codes originate from the Contract Pharmacy at the time it enters the patient demographics as part as the prescription, which is then captured by the switch provider. Patient Residence Codes were determined by CMS and have been required since 2014 for all Medicare transactions.
Q. Are these Patient Residence Codes for retail?
A. Yes, Patient Residence Codes are transmitted via Retail prescriptions only. However, hospital users have the option to exclude Patient Residence Codes.
View Qualification Filters