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Guides and Tips

Empowering your pharmacy to generate new forms of revenue through the process of credentialing and contracting is the goal of STRAND's Training Center. By achieving an In-Network (Contracted) status with Insurance Payers you now have the ability to receive reimbursement for clinical services. Examples of these services would be: Diabetes Self-Management Education (DSME) and participation in the Diabetes Prevention Program (DPP). Many other clinical/billable services may be available in your state.

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The Most Common Credentialing and Contracting Steps:

1. Gather Your Information
   • Type 1 NPI (Individual), if required
   • Type 2 NPI (Pharmacy)
   • Pharmacy's Tax ID
   • Pharmacy's Ownership Information
   • Copy of Your Diploma
   • Copy of Your Pharmacy License
   • Copy of Your Pharmacy/Business License
   • Copy of  Your Certifications (such as AADE Accreditation Certificate)
2. Identify which Payers you want to engage.
3. Navigate to your state's training center page, in order to obtain and complete enrollment forms.
4. Submit your enrollment applications directly to the payer via the notated method.
5. Once the payer accepts the enrollment application, the payer will provide a contract with reimbursement rates (fee schedule) and services notated.
6. An 837 Electronic Data Interchange (EDI) must be established by you. The EDI assures HIPAA compliant electronic billing standards are met by verifying a pathway to submit health care claim billing information, encounter information, or both.
7. Review the Claims Training Videos for additional resources and FAQ's.
8. Get started billing the payer and receiving new revenue!

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Top 4 Questions Answered:

1. You may need a CAQH Profile
2. The Common Payer response time is 30-90 days from application submission
3. You are responsible for contacting the Payer's Provider Enrollment department (portal or phone number) to obtain an application status and updates.
   • Common Reasons for Denied Applications:
     • Misspelled Legal Business Name
     • Incomplete Application
     • Not uploading supporting documentation, such as copies of required licenses, certifications, etc.
     • The NPI was entered incorrectly and/or the Type 1 NPI was entered instead of the Type 2 NPI
4. When you receive a response, make sure that your enrollment covers the Medical Benefit rather than Pharmacy Benefit

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Taxonomy Codes

In order to become correctly contracted with a payer, you must identify your specialty/specialties appropriately. This is accomplished using taxonomy codes that are associated with your NPI. In order to offer clinical services, you will need to reflect certain specific taxonomy codes. To update your Taxonomy Codes please visit the NPPES website here.

Common Taxonomy Codes and Issues: 

• • 1. If you are updating your taxonomy code for your Pharmacy NPI (type 2 NPI) do NOT add the taxonomy code for an individual Pharmacist (183500000X), but rather choose the one for Pharmacy (333600000X). Associating the incorrect pharmacy/pharmacist taxonomy code will cause your enrollment applications with payers to be rejected.
    2. Some commonly used Taxonomy Codes are:
    • • 333600000X Pharmacy A facility used by pharmacists for the compounding and dispensing of medicinal preparations and other associated professional and administrative services. A pharmacy is a facility whose primary function is to store, prepare and legally dispense prescription drugs under the professional supervision of a licensed pharmacist. It meets any licensing or certification standards set forth by the jurisdiction where it is located.
      • 3336C0002X Clinic Pharmacy A pharmacy in a clinic, emergency room or hospital (outpatient) that dispenses medications to patients for self-administration under the supervision of a pharmacist.
      • 3336C0003X Community/Retail Pharmacy A pharmacy where pharmacists store, prepare, and dispense medicinal preparations and/or prescriptions for a local patient population in accordance with federal and state law; counsel patients and caregivers (sometimes independent of the dispensing process); administer vaccinations; and provide other professional services associated with pharmaceutical care such as health screenings, consultative services with other health care providers, collaborative practice, disease state management, and education classes.
      • 3336C0004X Compounding Pharmacy A pharmacy that specializes in the preparation of components into a drug preparation as the result of a Practitioner?s Prescription Drug Order or initiative based on the Practitioner/Patient/Pharmacist relationship in the course of professional practice. A compounding pharmacy utilizes specialized equipment and specially designed facilities necessary to meet the legal and quality requirements of its scope of compounding practice.
      • 3336H0001X Home Infusion Therapy Pharmacy Pharmacy-based, decentralized patient care organization with expertise in USP 797-compliant sterile drug compounding that provides care to patients with acute or chronic conditions generally pertaining to parenteral administration of drugs, biologics and nutritional formulae administered through catheters and/or needles in the home and alternate sites. Extensive professional pharmacy services, care coordination, infusion nursing services, supplies, and equipment are provided to optimize efficacy and compliance.
      • 3336L0003X Long Term Care Pharmacy A pharmacy that dispenses medicinal preparations delivered to patients residing within an intermediate or skilled nursing facility, including intermediate care facilities for mentally retarded, hospice, assisted living facilities, group homes, and other forms of congregate living arrangements.
      • 3336S0011X Specialty Pharmacy A pharmacy that dispenses generally low volume and high-cost medicinal preparations to patients who are undergoing intensive therapies for illnesses that are generally chronic, complex and potentially life-threatening. Often these therapies require specialized delivery and administration.
      • 183500000X Pharmacist An individual licensed by the appropriate state regulatory agency to engage in the practice of pharmacy. The practice of pharmacy includes, but is not limited to, assessment, interpretation, evaluation, and implementation, initiation, monitoring or modification of medication and or medical orders; the compounding or dispensing of medication and or medical orders; participation in drug and device procurement, storage, and selection; drug administration; drug regimen reviews; drug or drug-related research; provision of patient education and the provision of those acts or services necessary to provide medication therapy management services in all areas of patient care.
      • 1835P0018X Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist Pharmacist Clinician/Clinical Pharmacy Specialist is a pharmacist with additional training and an expanded scope of practice that may include prescriptive authority, therapeutic management, and disease management.
      • 163WD0400X Diabetes Educator Providers who offer Diabetes Self-Management Education/Training services.
      • 174H00000X Health Educator Health educators work in a variety of settings providing education to individuals or groups of individuals on healthy behaviors, wellness, and health-related topics with the goal of preventing diseases and health problems. Health educators generally require a bachelor's degree and may receive additional training, such as through mentoring, internships, or volunteer work.

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Health Care Code Resources

1. Claim Adjustment Reason Codes - CARCs (notates the reason for a payment adjustment and describes why a claim or service line was paid differently than it was billed.)
2. Remittance Advice Reason Codes - RARCs (provides additional explanation for an adjustment already described by a CARC or to convey information about remittance processing.)
3. Claim Status Category Codes (indicates the general category of a claim’s status)
4. Claim Status Codes (conveys the status of an entire claim or a specific service line.)
5. Health Care Services Decision Reason Codes (communicates the reason for the health care services review outcome.)
6. Insurance Business Process Application Error Codes (reports application errors for insurance and business processes)

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Collaborative Practice Agreement Resources

• CDC Resource for Pharmacists
• 2013 State Fact Sheet
• Collaborative Drug Therapy Management with a CPA

 

Template – reusable blocks

Empowering your pharmacy to generate new forms of revenue through the process of credentialing and contracting is the goal of STRAND’s Training Center. By achieving an In-Network (Contracted) status with Insurance Payers you now have the ability to receive reimbursement for clinical services. Examples of these services would be: Diabetes Self-Management Education (DSME) and participation in the Diabetes Prevention Program (DPP). Many other clinical/billable services may be available in your state.

---

The Most Common Credentialing and Contracting Steps:

1. Gather Your Information
   • Type 1 NPI (Individual), if required
   • Type 2 NPI (Pharmacy)
   • Pharmacy’s Tax ID
   • Pharmacy’s Ownership Information
   • Copy of Your Diploma
   • Copy of Your Pharmacy License
   • Copy of Your Pharmacy/Business License
   • Copy of  Your Certifications (such as AADE Accreditation Certificate)
2. Identify which Payers you want to engage.
3. Navigate to your state’s training center page, in order to obtain and complete enrollment forms.
4. Submit your enrollment applications directly to the payer via the notated method.
5. Once the payer accepts the enrollment application, the payer will provide a contract with reimbursement rates (fee schedule) and services notated.
6. An 837 Electronic Data Interchange (EDI) must be established by you. The EDI assures HIPAA compliant electronic billing standards are met by verifying a pathway to submit health care claim billing information, encounter information, or both.
7. Review the Claims Training Videos for additional resources and FAQ’s.
8. Get started billing the payer and receiving new revenue!

---

Top 4 Questions Answered:

1. You may need a CAQH Profile
2. The Common Payer response time is 30-90 days from application submission
3. You are responsible for contacting the Payer’s Provider Enrollment department (portal or phone number) to obtain an application status and updates.
   • Common Reasons for Denied Applications:
     • Misspelled Legal Business Name
     • Incomplete Application
     • Not uploading supporting documentation, such as copies of required licenses, certifications, etc.
     • The NPI was entered incorrectly and/or the Type 1 NPI was entered instead of the Type 2 NPI
4. When you receive a response, make sure that your enrollment covers the Medical Benefit rather than Pharmacy Benefit

---

Taxonomy Codes

In order to become correctly contracted with a payer, you must identify your specialty/specialties appropriately. This is accomplished using taxonomy codes that are associated with your NPI. In order to offer clinical services, you will need to reflect certain specific taxonomy codes. To update your Taxonomy Codes please visit the NPPES website here.

Common Taxonomy Codes and Issues: 

• • 1. If you are updating your taxonomy code for your Pharmacy NPI (type 2 NPI) do NOT add the taxonomy code for an individual Pharmacist (183500000X), but rather choose the one for Pharmacy (333600000X). Associating the incorrect pharmacy/pharmacist taxonomy code will cause your enrollment applications with payers to be rejected.
    2. Some commonly used Taxonomy Codes are:
    • • 333600000X Pharmacy A facility used by pharmacists for the compounding and dispensing of medicinal preparations and other associated professional and administrative services. A pharmacy is a facility whose primary function is to store, prepare and legally dispense prescription drugs under the professional supervision of a licensed pharmacist. It meets any licensing or certification standards set forth by the jurisdiction where it is located.
      • 3336C0002X Clinic Pharmacy A pharmacy in a clinic, emergency room or hospital (outpatient) that dispenses medications to patients for self-administration under the supervision of a pharmacist.
      • 3336C0003X Community/Retail Pharmacy A pharmacy where pharmacists store, prepare, and dispense medicinal preparations and/or prescriptions for a local patient population in accordance with federal and state law; counsel patients and caregivers (sometimes independent of the dispensing process); administer vaccinations; and provide other professional services associated with pharmaceutical care such as health screenings, consultative services with other health care providers, collaborative practice, disease state management, and education classes.
      • 3336C0004X Compounding Pharmacy A pharmacy that specializes in the preparation of components into a drug preparation as the result of a Practitioner?s Prescription Drug Order or initiative based on the Practitioner/Patient/Pharmacist relationship in the course of professional practice. A compounding pharmacy utilizes specialized equipment and specially designed facilities necessary to meet the legal and quality requirements of its scope of compounding practice.
      • 3336H0001X Home Infusion Therapy Pharmacy Pharmacy-based, decentralized patient care organization with expertise in USP 797-compliant sterile drug compounding that provides care to patients with acute or chronic conditions generally pertaining to parenteral administration of drugs, biologics and nutritional formulae administered through catheters and/or needles in the home and alternate sites. Extensive professional pharmacy services, care coordination, infusion nursing services, supplies, and equipment are provided to optimize efficacy and compliance.
      • 3336L0003X Long Term Care Pharmacy A pharmacy that dispenses medicinal preparations delivered to patients residing within an intermediate or skilled nursing facility, including intermediate care facilities for mentally retarded, hospice, assisted living facilities, group homes, and other forms of congregate living arrangements.
      • 3336S0011X Specialty Pharmacy A pharmacy that dispenses generally low volume and high-cost medicinal preparations to patients who are undergoing intensive therapies for illnesses that are generally chronic, complex and potentially life-threatening. Often these therapies require specialized delivery and administration.
      • 183500000X Pharmacist An individual licensed by the appropriate state regulatory agency to engage in the practice of pharmacy. The practice of pharmacy includes, but is not limited to, assessment, interpretation, evaluation, and implementation, initiation, monitoring or modification of medication and or medical orders; the compounding or dispensing of medication and or medical orders; participation in drug and device procurement, storage, and selection; drug administration; drug regimen reviews; drug or drug-related research; provision of patient education and the provision of those acts or services necessary to provide medication therapy management services in all areas of patient care.
      • 1835P0018X Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist Pharmacist Clinician/Clinical Pharmacy Specialist is a pharmacist with additional training and an expanded scope of practice that may include prescriptive authority, therapeutic management, and disease management.
      • 163WD0400X Diabetes Educator Providers who offer Diabetes Self-Management Education/Training services.
      • 174H00000X Health Educator Health educators work in a variety of settings providing education to individuals or groups of individuals on healthy behaviors, wellness, and health-related topics with the goal of preventing diseases and health problems. Health educators generally require a bachelor’s degree and may receive additional training, such as through mentoring, internships, or volunteer work.

---

Health Care Code Resources

1. Claim Adjustment Reason Codes – CARCs (notates the reason for a payment adjustment and describes why a claim or service line was paid differently than it was billed.)
2. Remittance Advice Reason Codes – RARCs (provides additional explanation for an adjustment already described by a CARC or to convey information about remittance processing.)
3. Claim Status Category Codes (indicates the general category of a claim’s status)
4. Claim Status Codes (conveys the status of an entire claim or a specific service line.)
5. Health Care Services Decision Reason Codes (communicates the reason for the health care services review outcome.)
6. Insurance Business Process Application Error Codes (reports application errors for insurance and business processes)

---

Collaborative Practice Agreement Resources

• CDC Resource for Pharmacists
• 2013 State Fact Sheet
• Collaborative Drug Therapy Management with a CPA

 

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The Basics

Credentialing Specifics