Operational efficacy

• Streamline workflow — automate routine tasks and optimise pharmacy processes; and
• Ensure all staff members are proficient in the claiming practice to promote consistency and accuracy.

Product File update

• Keep the IPU Product File updated to stay up to date with all product GMS codes and prices. Ask your PMR Vendor to activate the IPU Product File Web Service, which automatically updates the Product File.

 

Dispensing process

• Check the validity of the prescription — it must meet all legislative and regulatory requirements to be eligible for reimbursement;
• Check patient’s approvals — the PCRS Secure Scheme Checker on the PCRS Pharmacy Application Suite shows patient individual approvals (excluding EMPs) as well as the expiry date of the approval;
• Check item quantity restrictions — respect the maximum monthly allowance based on the product SmPC or PCRS Circulars;
• Check items subjected to restricted reimbursement — the IPU’s Restricted Reimbursement Guide and a Summary of Items with Restrictions Guide outline the current known reimbursement restrictions (available at ipu.ie);
• Proprietary branded version of reference priced items — only the reference price will be reimbursed unless the prescriber has written ‘Do Not Substitute’ against the proprietary branded version;
• GMS scheme: When dispensing a GMS script, ensure a GP prescriber is included in the List of GPs with GMS Contracts published on PCRS Online Services — this is a dynamic file with the GMS codes of all GP prescribers with a GMS contract;
• GMS scheme: Ensure items claimed on the GMS scheme are on the List of Reimbursable Items (on PCRS Online Services) or have an EMP administrative code as listed in PCRS Circular 12/23. Note that some items on the list are subject to PCRS approval;
• DPS scheme: Check with Pharmacy Function by phoning 01 864 7100 (option 7) or emailing response@hse.ie to see if an EMP will be covered under the DPS scheme, before using a 777- code to claim for it;
• Dental scheme: Only dispense items listed on the Dental Prescribable Items – Nov 22 on the Dental scheme. Similarly, check if the dentist is listed on the List of Dentists with GMS contracts;
• LTI scheme: When dispensing under the LTI scheme, check if the item is on the LTI core approved list (available at hse.ie > Services > Schemes and allowances > Long-Term Illness Scheme), for the 16 Long-Term Illnesses. If it is not, seek individual reimbursement approval from the PCRS; and
• Hospital Emergency scheme: Ensure that 61559 is entered as the doctor’s GMS code when dispensing on the Hospital Emergency scheme.

 

Prescription endorsements

• Check the patient’s and prescriber’s GMS number are present on GMS prescriptions;
• Endorse prescriptions correctly — avoid missing out on payments or any delays to payments; and
• Check that prescriber endorsements are present, where applicable — for example, ‘Phased dispensing’ for items dispensed weekly and ‘Do not substitute’ for reference priced items where the patient is supplied with the proprietary brand without the payment of a co-payment.

Ordering management

Check with multiple suppliers before ordering to ensure you obtain the best price. Some products are only available at their reimbursement price directly from their agents or certain wholesalers, for example some Medtronic items;

• To purchase EMPs which have an administrative code at their reimbursement prices, use only suppliers indicated in HSE Circular 012/23;
• Report any products which cannot be purchased at reimbursement prices to datainfo@ipu.ie and the IPU Product File team will liaise with the company, and the IPU Contract Unit will liaise with the PCRS; and
• Report any medicine shortages or supply disruptions to the IPU Product File team at datainfo@ipu.ie.

 

End-of-month claiming

• Verify prescriptions for Community Drug Schemes daily. This is a critical task in pharmacy operations that ensures compliance with reimbursement requirements;
• Claim for the High-Tech Non-Dispensed Patient Care Fee;
• Run prescription reports — owings, loaned scripts;
• Follow up on any loaned scripts;
• Run item reports — zero-cost items, maximum monthly allowance;
• Run eligibility reports — phased dispensing, hardship, non-core LTI items;
• Check that all hospital emergency scripts have a 61559 doctor code;
• Check all emergency DPS and express LTI numbers in the claim file to see if they have received full eligibility;
• Run a software check for errors in your claim file if your PMR software supports it; and
• Check Tax Clearance Certificate status — it is important to have a process to ensure a valid Tax Clearance Certificate is in place before claims are sent.

 

Submitting claims for payment

• Follow the specified protocols for submitting claims to the PCRS, ensuring that all required information is accurately recorded and submitted;
• Ensure the claim file is transmitted electronically to the PCRS on time considering the designated timeframes for payments:
  • Early pay — electronic claims must be received by the PCRS no later than midnight on the third working day of the month; and
• Normal pay — files submitted after midnight on the third working day, and before midnight on the seventh day of the month, qualify for normal payment.
• Check that the claim file has been successfully sent by logging on to PCRS Pharmacy Application Suite > Claiming > Transmission History;
• Notify the PCRS immediately if you have any issues sending your claim file;
• Download your exception file on time — the file will be available within 24 hours of electronic submission;
• Resubmit the final corrected exception file by midnight on the eighth working day — early detection of discrepancies or missing information in claims prevents them from being rejected; and
• If you are selected to submit the ‘yellow bag’, deliver the paper bundle to the PCRS no later than the fifth day of the month.

 

Payment analysis and reconciliation against claims submitted for payment

• Keep a record of the email confirmation of any exceptional circumstances such as extra allowances, or patient-specific requirements to help with payment reconciliation;
• Analyse your monthly Summary Listings to identify any payment discrepancies or to identify any unusual trends or potential errors. The IPU Contract Unit recommends keeping a record or log of all expensive items dispensed each month to assist with reconciliation;
• Ask your PMR vendor to use the PCRS XML file. The PCRS supplies the file which can be used to reconcile your claims and payments and allows you to identify any discrepancies;
• Check and challenge any partially reimbursed claim; and
• Check that the total fees paid for the Contraception Scheme claims align with the quantities dispensed.

Resubmission of rejected claims

• Correct and submit reclaims as soon as possible — this will prevent the same mistakes from happening and eliminate recurring errors.

 

Support

Vendor support: Contact your vendor to make the most of any available functionalities to optimise your dispensing process or if you experience any issues with your claim submission.

HSE PCRS support: Check HSE PCRS circulars and the HSE PCRS Information and Administrative Arrangements for Pharmacists handbook for more information on the administration of Community Drug Schemes, available at pcrs.ie.

IPU Contract Unit support: Useful information is available on the Contract Section of the IPU website. If you believe there is an issue with your monthly payment or have outstanding reclaims, contact the IPU Contract Unit at contract@ipu.ie.