Expressscriptscanada Pharmacy Provider Manual En Version 0

Partial capture of text on file.

Pharmacy Provider Manual
APPLICABLE TO ALL PROVINCES AND TERRITORIES (EXCLUDING
QUÉBEC)
December 2019
Version 5.0
@ExpressRxCanada Express Scripts Canada Express Scripts Canada
 2019 Express Scripts Canada. All Rights Reserved.

Any comments or requests for information may be transmitted to:
Express Scripts Canada
Attention: Provider Relations
10th Floor
5770 Hurontario Street
Mississauga, ON L5R 3G5
Express Scripts Canada reserves the right to update this manual and content referenced in this manual. Data used
in examples are fictitious unless otherwise noted. In the event that there are discrepancies between the English
and the French version, the English version will prevail.
© 2009 – 2019 Express Scripts Canada. All Rights Reserved.
Express Scripts Canada is a registered business name of ESI Canada, an Ontario partnership.
All reproduction, adaptation or translation is prohibited without prior written authorization, except for cases
stipulated by the Copyright Act. Registered or non-registered trademarks and registered product names belong to
their respective owners.

@ExpressRxCanada Express Scripts Canada Express Scripts Canada 2

DOCUMENT REVISION HISTORY
Version Date last revised Publication date Details
1.0 December 2010 December 2010 Revision
2.0 November 2012 November 2012 Revision
3.0 April 2016 April 2016 Revision
3.1 February 2019 April 2019 Revision
4.0 June 2019 July 2019 Revision
5.0 December 2019 December 2019 Revision
Note: The publication date takes precedence over the date last revised.

@ExpressRxCanada Express Scripts Canada Express Scripts Canada 3

Table of Contents
1. DEFINED TERMS ...................................................................................................................................................................... 6
2. INTRODUCTION ......................................................................................................................................................................... 9
2.1. Purpose ........................................................................................................................................................................... 9
2.2. Terms ............................................................................................................................................................................... 9
2.3. Exemptions ...................................................................................................................................................................... 9
2.4. Role of Express Scripts Canada ................................................................................................................................... 10
2.5. Express Scripts Canada Services ................................................................................................................................. 10
2.6. Express Scripts Canada Clients ................................................................................................................................... 11
3. PHARMACY PROVIDER AGREEMENT ..................................................................................................................................... 12
3.1. Pharmacy Provider Agreement ..................................................................................................................................... 12
3.2. Liability Insurance and Indemnity ................................................................................................................................ 12
3.3. Pricing – Same Level Playing Field .............................................................................................................................. 13
4. AUDIT AND REVIEW PROGRAM.............................................................................................................................................. 13
4.1. Audit ............................................................................................................................................................................... 13
4.2. Audit Response ............................................................................................................................................................. 14
4.3. Provider Responsibility ................................................................................................................................................. 14
4.4. Review ........................................................................................................................................................................... 15
5. ADJUDICATION SYSTEM OVERVIEW ...................................................................................................................................... 16
5.1. Real-time Processing .................................................................................................................................................... 16
5.2. Adjudication System Functionality ............................................................................................................................... 16
5.3. Variations in Pharmacy Practice Management Systems (PPMS) ............................................................................... 16
6. ENROLMENT AND MODIFICATION TO PHARMACY PROVIDER INFORMATION .................................................................... 16
7. CLAIM REIMBURSEMENT PROCESS ..................................................................................................................................... 17
7.1. Pharmacy Provider Reimbursement ............................................................................................................................ 17
7.2. Net Reimbursement ...................................................................................................................................................... 17
8. CLAIM SUBMISSION PROCESS .............................................................................................................................................. 18
8.1. Claim Submission Requirements -- General ................................................................................................................ 18
8.2. Direct Electronic Claim Submissions ........................................................................................................................... 19
8.3. Deferred Claim Submissions ........................................................................................................................................ 20
8.4. Manual Claim Submissions – Claims Exceeding $9,999.99 ..................................................................................... 20
8.5. Compound Claim Submissions .................................................................................................................................... 21
8.6. Methadone and Suboxone® Claim Submissions ....................................................................................................... 22
8.7. Medical Cannabis Claim Submissions ......................................................................................................................... 22
9. CLAIM REVERSALS ................................................................................................................................................................. 22
9.1. Electronic Claim Reversals ........................................................................................................................................... 22
9.2. Deferred Claim Reversals ............................................................................................................................................. 23
9.3. Manual Claim Reversals ............................................................................................................................................... 23
@ExpressRxCanada Express Scripts Canada Express Scripts Canada 4

The words contained in this file might help you see if this file matches what you are looking for:

...Pharmacy provider manual applicable to all provinces and territories excluding quebec december version expressrxcanada express scripts canada rights reserved any comments or requests for information may be transmitted attention relations th floor hurontario street mississauga on lr g reserves the right update this content referenced in data used examples are fictitious unless otherwise noted event that there discrepancies between english french will prevail is a registered business name of esi an ontario partnership reproduction adaptation translation prohibited without prior written authorization except cases stipulated by copyright act non trademarks product names belong their respective owners document revision history date last revised publication details november april february june july note takes precedence over table contents defined terms introduction purpose exemptions role services clients agreement liability insurance indemnity pricing same level playing field audit review ...

Related files

Share

Help

Related files

Share

Share to social media

Help

Login Area