TELUS Health will issue a provider number to a pharmacy that wishes to submit electronic transactions to us processing. Prior to issuing a provider number, a several factors are considered, and the pharmacy must meet the following criteria:
- The pharmacy must be a dispensing facility and licensed/accredited by the appropriate provincial governing licensing body, and it must be operated by licensed pharmacist(s) in good standing.
- If the physician(s) own and/or have a financial interest in the pharmacy, the physician(s) and all medical office staff cannot be participants in the management and/or operation of the pharmacy.
- Where an accredited pharmacy wishes to have claims submitted to TELUS Health via an accredited remote dispensing facility (including remote dispensing location, automated pharmacy system and dispensing kiosk), the accredited pharmacy must apply for a provider number for the accredited remote dispensing facility. Upon meeting all the requirements of the provider number issuance assessment, TELUS Health will issue a unique provider number to the accredited remote dispensing facility. The accredited pharmacy is prohibited from using its existing TELUS Health provider number for claims submitted through the remote dispensing facility.
In exceptional circumstances, if a physician also dispenses prescriptions, we will consider issuing a provider number to the physician if and only if there is not a registered pharmacy within 30 kilometers of the physician’s clinic. The physician must provide us with proof of being a licensed dispensing physician. Contact our Support Centre for more information.
Some of our insurers’ cardholders have advised us that some pharmacists do not explain why a particular claim was rejected. The patients have complained that their pharmacists simply say “This card doesn’t work!”
Many common reasons for a claim being rejected include:
- A dependant not registered (i.e. a new birth, new spouse, etc.),
- Incorrect dependant code,
- The dependant is now above the age specified for coverage, and
- An incorrect date of birth has been submitted.
The Pharmacy Policies and Procedures Manual (pdf) details the types of messages you may receive on your software (section 3, pages 9 – 10). If you receive one of many eligibility messages, please relay this information to your patient. If a coverage problem occurs, the patient must be directed to advise the plan sponsor’s benefits office in order to register the new dependent, ensure the correct date of birth, or ensure the appropriate information concerning a full-time student dependant has been given to the benefits office. Once the updated information has been relayed to the insurance company, the files will be updated electronically. Please note that until the plan sponsor notifies their insurer, these reject messages will continue to occur.
The Pharmacy Support Centre is reserved for pharmacists and dentists only. When you dial in, choose Option 1 on our automated system to be connected with the Pharmacy Support Centre. We also offer a Physician Support Centre at 1-888-668-1308. Doctors may call this number for information on TELUS Health drug plans. Customer questions that cannot be answered by the pharmacist should be directed to the customer’s human resources administrator or their insurance carrier.
The average call takes approximately 3 minutes although many will take less time.
We receive in excess of 900 calls each weekday and over 500 calls on the weekends.
No. All changes must come from the insurance carrier.
Very important! TELUS Health uses the DOB as an identifying feature, along with the relationship code. If the date of birth entered by the pharmacy does not match the date of birth we have on file, the claim will be declined. The same is true if the relationship code entered by the pharmacy does not match the relationship code we have on file.
TELUS Health uses the date of birth as one of our key identifying features. As such it is imperative that the pharmacist enters the correct date of birth to ensure the proper identity of the individual using the Assure Card®. If the Support Centre gave out this information it would compromise the integrity of the identification process.
We are only allowed to confirm whether or not the birth date you have on file is the same as the one supplied to us by the insurance carrier. If the patient confirms that the birth date you have on file is correct but it differs from our patient information, then the patient must contact his or her employer in order to rectify the situation. The insurance carrier will inform us of the revised information shortly after receiving notification of the required change from the employee.
If this situation arises and the patient cannot wait for the information to be corrected (it may take a few days), the patient should pay cash and submit the receipt to TELUS Health for direct reimbursement.
Just as input of the right birth date in the right format is critical to the EDI adjudication process, so is the correct Relationship Code (Rel. Code) for the patient for whom drugs are being dispensed. Use of the proper Rel. Code is important for us to be able to validate claims as well as administer Drug Utilization Review and various individual plan limits such as deductibles, maximums, out-of-pocket accumulators, etc.
We use the following Rel. Codes and associated descriptions
|01||The Primary Cardholder – usually the employee of the policyholder. The name of the primary cardholder almost always appears on the card.|
|02||Spouse of the Primary Cardholder. In some instances, the name of the spouse appears on the card, either secondary to that of the Primary Cardholder, or by itself. A separate card may be issued in the name of the spouse alone in such cases as when the spouse goes by a different surname.|
|03||Dependent Child of the Primary Cardholder – usually a minor up to age 18 or 19, but could be 20 or older, depending on the terms of the Group Benefit Plan.|
|04||Overage Dependent Child of the Primary Cardholder – is still eligible for coverage because of continuing full-time education. In some cases, separate cards are issued in the name of the overage student. Such cards will be embossed with the letters “OA” and an expiry date; usually the end of the school year.|
|05||Overage Disabled Dependent Child of the Primary Cardholder – is still eligible for coverage because of a mentally or physically disabling condition. In some cases, separate cards are issued in the name of the disabled dependent. Such cards will be embossed with the letters “DD”.|
Use of the correct Rel. Code with the wrong date of birth will result in rejection of the claim. This also applies to use of the right date of birth with the wrong Rel. Code. It is essential that both match the information in our system in order to facilitate payment.
A standard part of the Assure Card® is our Concurrent Drug Utilization Review service. This additional source of information can enhance your customer service capabilities by checking for potential problems that may not be covered by your pharmacy practice software.
In order for the program to work effectively it is vital that we receive the correct days supply information. The majority of our plans offer dispensing limitations of a 34 day supply for non-maintenance medications and a 100 day supply for maintenance medications. (Please refer to your pharmacy manual (pdf) for a description of the maintenance classification.) Proper use of the days supply field is critical to ensure proper claims payments and Drug Utilization Review messages.
Note: With PRN (take as needed) and Take as Directed medications, determining the proper days supply can be difficult. In these cases, a realistic estimate is all that is required.
Perhaps the most difficult pharmacy product to adjudicate online in real time is the extemporaneous mixture or compound. Although fewer than 1.2% of the claims we receive electronically are compounds, they take 15% of the time of our internal auditors to determine eligibility. We know that pharmacies are also frustrated if a compound is prepared and a claim transmitted to us, only to find out much later that it did not satisfy the audit criteria.
A compound is reimbursed by us only if the primary active ingredient is normally covered by the patient’s drug plan and it is not merely a duplicate of a commercially available drug product. To avoid having a claim reversed days or weeks after your customer has left the store, you can call our Pharmacy Support Centre at the time of preparation to determine if it qualifies under the plan. If none of a compound’s ingredients require a prescription, a call to the Support Centre to confirm coverage will help avoid an unexpected reject.
A compound preparation is one that does not duplicate the formulation of a commercially manufactured drug product. Whenever possible, we require that you transmit compound claims using the DIN of the principle prescription-requiring ingredient in that compound (if applicable). This will ensure an online eligibility check of the DIN/PIN you have transmitted. An example would be hydrocortisone 1% cream and clotrimazole cream, compounded in equal parts – please transmit the compound with the hydrocortisone cream DIN and the appropriate compound code. The hydrocortisone cream is a prescription-requiring ingredient and is likely to be eligible on most plans whereas the clotrimazole cream is OTC and not eligible on most plans. If your compound contains no prescription-requiring ingredients, please transmit using one of the ingredient DINs. If you must use a general compound PIN (e.g. 00999999, 00900710) to submit a claim, we strongly recommend that you contact our Claims Pharmacy Service Desk to confirm eligibility. Consult our Pharmacy Support Tools for our most recent pseudo-DIN list.
Reminder: While diabetic test strips, disposable insulin syringes, needles and lancets are eligible on most plans, GLUCOMETERS and DEVICES to use with lancets are NOT eligible. When submitting compound DINs for mixtures, please be advised that at least one of the ingredients must be considered eligible. Mixtures of Aquaphor (Eucerin), Glycerin and Water would not be eligible on any of our plans. If you are in doubt concerning eligible mixtures, please call the Support Centre for assistance.
TELUS Health adjudicates claims on the basis of a pharmacy’s usual and customary professional fee. These fees may be established by provincial legislation, negotiations with Provincial Pharmacy Associations or individually with each pharmacy, as is the case in Ontario, for example.
Once an amount is reported to us and coded into the adjudication system, we can fully support the processing of the pharmacy’s usual & customary fee. Where permitted, as far as we are concerned, providers remain free to charge the fee they choose as long as they charge cash customers and third party payors the same amount. Some provinces, such as Ontario, require that this amount be reported to a Provincial Licensing Body in addition to being publicly posted in the store.
In order to ensure that TELUS Health processes the fee portion of the submitted transaction according to your pharmacy’s usual & customary amount, please notify TELUS Health of any changes. Please complete the Provider Change Form, indicate the new usual and customary fee, the date when the change takes effect and fax to 1 866 840-1466.
We often hear from pharmacy customers that they have had to pay for ingredient price cutbacks. Our price files are established from various reliable sources and allow a reasonable markup. In Quebec, pricing is addressed in our agreement with AQPP. Part of your agreement with us is that you will accept our adjudicated ingredient cost payment and not charge your customer any excess amount.
If you have paid more for a drug than we allowed during adjudication, please contact our TELUS Health Support Centre. You will then be asked to fax in a recent invoice, referencing the ticket number assigned to your inquiry, and we will make the necessary adjustment. The only limitations are that the variance on your submitted claim must be greater than $2.00 and your supporting invoice must be received within 7 days of the dispense date.
Most plans have various forms of co-payment (deductibles, co-pays, co-insurance) requiring the cardholder to pay a share of the cost of medication. Some plans have dispensing fee caps or deductibles equal to dispense fees that limit the professional fees the plan will pay. Other plans limit payment to the cost of alternative drugs, such as generics or drugs on a controlled formulary, but the customer may insist on receiving the product actually prescribed. You are able to collect cash from your customer for the amount of the co-payment, any amount by which your normal professional fee exceeds the fee cap and the price differential between the alternative product, if any, and the dispensed product. Should questions arise, please call our Pharmacy Support Centre and ask to have one of our pharmacists call you. They will be pleased to address your concerns and will appreciate your help in notifying us of problems that our practices create for you on the front lines.
EDI pay-direct drug plans are an increasingly popular employee benefit that is advantageous to both pharmacy and your customers. The concept that EDI customers should be charged no more than your regular price is critical to its success. This includes charges for oral contraceptives and diabetic supplies where reduced dispensing fees often apply. That is, you should bill no more for a TELUS Health EDI customer than you would charge cash customers or other pay-direct customers. In fact, your contract with us includes this requirement.
This means that, if you make special deals with any other pay-direct networks, you must apply the same pricing concessions to our cardholders. We provide you with a level playing field with your competitors. Our affiliated insurers must be accorded the same cost basis as you provide our competitors. (Note: This does not preclude you from entering into preferred provider arrangements with single employers or industry-based association groups.)
Payment can be reduced for a number of reasons. A DIN price can be cut back if the pharmacy submits a DIN price in excess of what the TELUS Health DIN price file will pay. Dispensing fees can be cut back if the pharmacy submits a dispensing fee in excess of the usual and customary fee. TELUS Health will pay or if there is a dispensing fee maximum in place for the group. DIN cutbacks can also occur if a drug plan has implemented generic substitution, reference-based pricing and/or maximum-allowable cost pricing. As well, DIN cutbacks can occur if the days supply for a medication exceeds 34 days for acute drugs or 100 days for maintenance drugs.
When the Assure Card® is presented at your pharmacy, always ask if the name listed on the card is that of the cardholder. Under some plans, every family member has their own card embossed with their name. It never hurts to ask!
TELUS Health administers drug plans on behalf of major Canadian Life Insurance Companies. They have given us the mandate to deal with pharmacies and other electronic providers on their behalf in order to facilitate the operation of their various pay-direct benefit programs. The insurers value and want to maintain their relationships with plan sponsors (employers) and their employees and have asked that we have no direct connect with either constituency. We respect their wishes.
We realize that this can occasionally put the pharmacy in the situation of dealing with an unhappy customer. Sometimes it’s unavoidable. Our Support Centre tries to provide you with as much information as possible to help your customer; but sometimes, it’s not enough to overcome the problem.
In such cases, all you can do is advise your customer to contact their employer’s plan administrator in order to get satisfaction from the insurer. If the issue has resulted in non-payment of the claim, your best course of action is to collect cash. When the problem is resolved, the cardholder can submit the receipt to the insurer for reimbursement.