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Revised 3.30.

2018
Contents
Introduction…………………………………………………………………………………………………. 3
OutcomesMTM Participation…………………………………………………………………………….. 3
User Access to Protected Health Information (PHI) 3
Participation From Various Settings…………………………………………………………………… 3
Retail 3
LTC/Assisted Living 3
Ambulatory Care – Physician Clinic 4
Acute Care 4
Use of Third Parties 4
MTM Center Pharmacist and Personnel Responsibilities………………………………………….. 4
Pharmacist 4
Technician/Pharmacy Intern or Student 5
Pharmacy Administrator 5
General Documentation Requirements…………………………………………………………………5
Cognitive Impairment Determinations & Authorized 6
Returned Mail 7
Patient Opt-Out Procedures 7
Patient Health Plan Complaints 7
Data Retention 7
General Billing Information…………………………………………………………………………........ 7
Documentation Requirements for Billable Services………………………………………………… 8
Comprehensive Medication Reviews 8
Needs Medication Reconciliation 9
Prescriber Consultations 10
Patient Adherence Consultations 13
Patient Education and Monitoring 17
Refusals and Unable to Reach After 3 Attempts 18
No Intervention Needed 19
Auditing and Monitoring………………………………………………………………………………….. 19
Quality Assurance 19
Claim Status Categories 19
Fraud, Waste and Abuse 20
Resolving QA Issues 20
Corrective Action 20
Compliance and Regulation……………………………………………………………………………… 21
Applicable Laws and Regulations 21
Kansas Medicaid Immigration Reform and Control Requirements 22
Appendix A. Glossary of Terms………………………………………………………………………….22

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Introduction
These policies and procedures outline requirements for providing and documenting MTM services in
OutcomesMTM programs. If an MTM Center or MTM Center personnel is in violation of an OutcomesMTM policy,
OutcomesMTM will take corrective action, including, but not limited to; corrective outreach and monitoring,
removing Connect™ Platform access, or terminating the MTM Center’s network participation agreement.

MTM Providers, or those seeking to become providers, in the OutcomesMTM Network can access Technical
Specialists via phone and email for assistance during business hours.
• Business hours are 7 AM to 7 PM Central Time, Monday through Friday
• Telephone support is available at 877.237.0050.
• Email support is available at info@outcomesmtm.com.

This document includes information, concepts, and intellectual property that is not to be duplicated, used, or
disclosed in-whole or in-part for any purpose other than by contracted entities in the OutcomesMTM Network in
the provision of covered services for OutcomesMTM eligible patients.

OutcomesMTM Participation
Pharmacies and other entities seeking to become authorized MTM Providers in the OutcomesMTM Network must
first complete a network participation agreement available at outcomesmtm.com. All MTM Center personnel are
required to individually create an account and pass the OutcomesMTM online training. After contract execution
and successful completion of training, MTM Providers will use the Connect™ Platform to access MTM
opportunities for OutcomesMTM eligible patients and submit required documentation for reimbursement.

Licensed pharmacists employed by a pharmacy or other approved MTM Center are approved MTM Providers in
the OutcomesMTM program. Nurses, prescribers and other non-pharmacy professionals are not authorized to
deliver MTM services unless approved by the health plan.

User Access to Protected Health Information (PHI)


An administrator shall be designated by the MTM Center to provide oversight of user roles and access. It is the
responsibility of the administrator for each MTM Center to monitor and approve/remove user access to PHI
maintained on the OutcomesMTM platform at least monthly. In instances where an administrator is not
established for an MTM Center, OutcomesMTM will request 3rd-party employment verification in order to approve
user access. The MTM Center is still responsible for monitoring and removing user access to PHI. Only
pharmacists approved by the MTM Center shall perform, document and bill for MTM services in OutcomesMTM
programs. User access to PHI will be restricted if the user has been inactive for ≥60 days.

Participation from Various Settings


MTM Providers employed by contracted MTM Centers may deliver MTM services to OutcomesMTM eligible
patients. To access MTM Opportunities, MTM Center personnel must be granted permission to by an
administrator of the MTM Center. Based on the healthcare setting some MTM services may be restricted.

Retail
OutcomesMTM will populate an MTM Opportunity List for the MTM Center in the Connect™ Platform. The MTM
Opportunity List contains patients who have filled at least one medication within the past six months at the
pharmacy. Pharmacists may provide and document covered services the patient may be eligible to receive by
his/her health plan.

LTC/Assisted Living
Pharmacists located in or serving patients who reside in long-term care facilities or other types of institutional
living quarters may only provide a limited menu of covered services to OutcomesMTM eligible patients. Similarly,
pharmacists serving patients whose medications are administered by another healthcare professional may also
only provide a limited menu of covered service to OutcomesMTM eligible patients.

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In these unique circumstances, to determine if a patient can receive a covered service, the pharmacist should first
assess who is responsible for the patient’s medication dosing/administration.
• If the patient or a family member/friend is responsible for medication dosing/administration, the patient is
eligible for the standard covered services. The pharmacist may provide and document all services the
patient may be eligible to receive through his/her health plan.
• If a facility staff member or healthcare professional is responsible for the patient’s medication
dosing/administration, the patient is only eligible for the Comprehensive Medication Review and
Prescriber Consultations. Comprehensive Medication Reviews are not the same as a chart review and
should not be delivered as such [For more information about the CMR service see Covered Services].
• If a facility staff member or healthcare professional is responsible for the patient’s medication
dosing/administration, the patient is not eligible for Patient Adherence Consultations and Patient
Education & Monitoring services. The pharmacist may not bill for these services even though the patient
may be eligible to receive them through his/her health plan.

Ambulatory Care – Physician Clinic


Pharmacists located in ambulatory care physician clinics may provide MTM services to OutcomesMTM eligible
patients who visit the clinic. For those seeking to become authorized MTM Providers please contact
OutcomesMTM for contract information.

Pharmacists cannot bill for an MTM service in the Connect™ platform if they have billed for that same cognitive
service elsewhere, including but not limited to:
• CPT codes (e.g. MTM services)
• HCPCS codes (e.g. Transitional Care Management, Medicare Wellness Visits, Diabetes Self-
Management Training/Education)
• Incident to billing
• Specific contracts with private payers

Acute Care
Pharmacists located in acute care facilities are not permitted to provide MTM services to OutcomesMTM eligible
patients while inpatient. Patients in these facilities are already receiving direct care from a healthcare professional
and MTM billing would be considered double billing for services.

Use of Third Parties


To maintain the integrity and quality of services provided through our programs, outsourcing or subcontracting
MTM opportunities by an MTM Center to an offsite, third-party pharmacist or consulting firm is not permitted.

MTM Center Pharmacist and Personnel Responsibilities


Unless otherwise permitted by a health plan, only the following roles are permitted to view and/or complete MTM
opportunities for OutcomesMTM eligible patients. Each role is unique and is only to be used by those individuals
who meet the requirements and are able to fulfill the responsibilities listed below.

Pharmacist
Pharmacists accessing MTM opportunities via the Connect™ Platform must maintain a license in good standing
with the board of pharmacy. All active licenses are to be maintained in the pharmacist’s OutcomesMTM profile.
OutcomesMTM requires each pharmacist to abide by the laws pertaining to MTM in the state in which he/she
practices pharmacy. For more information pertaining to state laws, please contact the respective state board of
pharmacy. If a pharmacist is found to be inadequately licensed, his/her claims will not be compensated and
participation may be terminated from the program.

Pharmacists accessing MTM opportunities via the Connect™ Platform must have successfully completed the
OutcomesMTM online training. Additionally, he/she must have been granted permission to accessing patient
health information via an MTM Center administrator. Pharmacists are liable for all services and claims in which
his/her name is associated. As such, pharmacists should never share account log in credentials with any other
individual or pharmacy personnel.

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Each MTM claim submitted for payment shall be delivered by an approved MTM Provider. Claims should not be
submitted by a pharmacist who was not involved in the MTM service delivery.

Pharmacy students may provide MTM services under the direct supervision of an approved MTM Provider at the
MTM Center. The pharmacist shall use his/her discretion in the level of oversight required based on the student’s
professional training. The pharmacist acknowledges and agrees that all clinical and therapeutic decisions relating
to the provision of MTM shall be the exclusive responsibility/liability of the approved MTM Provider supervising the
MTM service delivery by the student.

Pharmacists may allow a technician or pharmacy student to document a service in the Connect™ Platform on
his/her behalf. The pharmacist acknowledges and agrees that the documentation and billing responsibility/liability
remains with the pharmacist.

Technician/Pharmacy Intern or Student


The use of technicians and students in a supporting role is encouraged to maximize the time spent with the
patient/patient representative for the pharmacist. Each technician or student providing support for MTM services
is required to have his/her own user account for the Connect™ Platform and must successfully complete the
OutcomesMTM online training. He/she will document all claims under his or her account and will select the
pharmacist affiliated with the MTM Center who supervised/provided the service.
The below rules apply to the role of the technician/student in supporting MTM services.
a. A technician/student is permitted to:
i. Identify patients eligible for MTM services
ii. Alert pharmacists to billable MTM services
iii. Schedule MTM appointments for a pharmacist
iv. Collect a complete medication list from the patient prior to a CMR
v. Document MTM services provided by a pharmacist
vi. Distribute and monitor communications (e.g. Standard Patient Takeaway, prescriber fax
forms)
vii. Monitor claim status and advise pharmacist on documentation changes needed for
claims in Review & Resubmit status

Pharmacy students can provide MTM services under the supervision of an OutcomesMTM-trained, licensed
pharmacist physically onsite at the MTM Center (each MTM claim will need to have the supervising pharmacist
selected within claim submission). The pharmacist shall use their discretion in the level of oversight required
based on the student’s professional training. The pharmacist acknowledges and agrees that all clinical and
therapeutic decisions relating to the provision of MTM shall be the exclusive responsibility/liability of the
pharmacist.

Pharmacy Administrator
An administrator shall be designated by the MTM Center to provide oversight of user roles and access. The
administrator is responsible for granting and removing user access to PHI for new or terminated employees. An
administrator should only grant access to the Connect™ Platform after the requesting user’s employment and role
have been verified. Pharmacy interns should always be assigned the Tech/Pharm Intern or Student role. The
Pharmacist role is only for those individuals that have obtained pharmacist licensure by the state Board of
Pharmacy. The administrator acknowledges and agrees that government mandated oversight is being performed
on all users in which he/she grants access to the Connect™ Platform. For more information, see Applicable Laws
and Regulations.

General Documentation Requirements


The following documentation requirements apply to all OutcomesMTM covered services. See Documentation
Requirements for Billable Services on page six for delivery and documentation requirements for each MTM
opportunity.

• Each claim submitted via the Connect™ Platform is coded via a similar format.
o Indication for service (reason)

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o Service provided (action)
o Outcome of service (result)
o Additional information as required by the claim type

• Only one MTM claim may be submitted per intervention.


o For example, if a pharmacist initiates a medication change due to suboptimal therapy a Suboptimal
Drug – Discontinued Therapy claim and a Needs Drug Therapy - Initiated New Therapy claim for the
medication change cannot be submitted. Instead, only the Suboptimal Drug - Changed Drug claim
should be submitted for the intervention.

• A severity level is required to be included on every MTM claim documented in the Connect™ Platform.
OutcomesMTM applies the healthcare cost that was avoided to the severity level selected. For more
information about severity levels, see page 26 Appendix A.
o OutcomesMTM pre-assigns severity levels for:
▪ Comprehensive Medication Reviews
▪ Patient Education and Monitoring claims pertaining to new or changed prescription therapy
▪ Patient Consultations affiliated with the Adherence Monitoring Program
▪ Patient/prescriber refusals
▪ Prescriber Consultations pertaining to cost efficacy
▪ All Unable to Reach After 3 Attempts claims
▪ All MTM claims resulting from a TIP
o The following claim types, if initiated by the pharmacist, require the pharmacist to document a
severity level and provide patient-specific information to support the severity level selected.
▪ Prescriber Consultations (except those pertaining to cost efficacy)
▪ Patient Adherence Consultations
▪ Patient Education & Monitoring claims pertaining to OTC therapy

• Each MTM claim is required to be submitted within 7 days of the date the outcome of the service was
determined; however, OutcomesMTM encourages MTM Providers to complete documentation and billing
immediately upon completion of the service to minimize the risk of the patient no longer being eligible at the
time of billing.

• All claims submitted are subject to quality assurance review. For more information, see Auditing and
Monitoring.

Cognitive Impairment Determinations & Authorized Representatives


In the event the MTM Provider determines the patient is cognitively impaired and unable to participate in a CMR,
we recommend the MTM Provider reach out to the patient’s caregiver, prescriber or other legally authorized
personal representative to take part in the CMR. This applies to patients in any setting and is not limited to
patients in long term care (LTC). If a legally authorized personal representative participates in the CMR on behalf
of the patient, it is the responsibility of the MTM Provider to verify and document the personal representative's
legal authority to act, such as a duly executed power of attorney or medical power of attorney, in compliance with
state laws and regulations. The verification of such documentation shall be available upon request.

If a patient is determined to be cognitively impaired, MTM Providers are required to document the rationale for the
cognitive impairment determination in the Connect Platform. Options for documentation include the following:
• Cognitive impairment: YES and unable to participate
o Brief Interview for Mental Status (BIMS) score
o Mini-mental state examination (MMSE) score <19
o Cognitive impairment noted in patient’s chart
o Confirmed status with family member/caregiver
o Confirmed status with healthcare staff
If the MTM Provider documents the patient is the recipient of the CMR in the Connect Platform, it is assumed the
patient has no cognitive impairment or is mildly cognitively impaired but was determined to be interviewable by
the MTM Provider.

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In general, the patient is interviewable if the patient demonstrates no short term or long term memory deficits, as
determined by the MTM Provider. The MTM Provider may choose, but is not required, to utilize one of the
available mental status assessments, such as the Brief Interview for Mental Status (BIMS) or Mini-mental state
examination (MMSE) assessments, to make this determination. The below assessment scores indicate the
patient has no cognitive impairment or is mildly cognitively impaired but may be interviewable.
o Brief Interview for Mental Status (BIMS) score ≥13
o Brief Interview for Mental Status (BIMS) score 8-12
▪ Mild cognitive impairment, but based on the MTM Provider’s professional judgment the
patient is able to manage their medications and is interviewable
o Mini-mental state examination (MMSE) score ≥24
o Mini-mental state examination (MMSE) score 19-23
▪ Mild cognitive impairment, but based on the MTM Provider’s professional judgment the
patient is able to manage their medications and is interviewable

Returned Mail
OutcomesMTM requires the CMR standard Patient Takeaway to be delivered to the patient within 7 days of the
date the CMR was completed. If the pharmacy delivers the Patient Takeaway via mail and the mail is returned,
contact the patient to verify/update address. The returned standard Patient Takeaway must be provided to the
patient as soon as possible to ensure compliance with CMS requirements. If the patient’s address cannot be
confirmed, the Patient Takeaway must be provided to the patient in person the next time the patient visits the
pharmacy. If the Patient Takeaway cannot be provided to the patient, you must notify OutcomesMTM. In order to
avoid returned mail, OutcomesMTM encourages pharmacists to verify the address during the CMR service.

Patient Opt-Out Procedures


An MTM-eligible patient may refuse or decline individual services without having to disenroll from the MTM
program. However, if an MTM-eligible patient requests to disenroll from the MTM program entirely, please contact
OutcomesMTM at 877.237.0050, so OutcomesMTM may notify the health plan of the disenrollment.

Patient Health Plan Complaints


If an MTM-eligible patient has a complaint about their health plan, please direct the patient to call the health plan
customer service phone number on the back of the prescription drug card or call OutcomesMTM at 877.237.0050
to obtain the appropriate phone number to provide to the patient.

Data Retention
Any back-up documentation utilized during the provision of service is required to be retained on-site for 10 years,
or as otherwise required by OutcomesMTM. Back-up documentation may include prescriber notes, CMR
Worksheets, Encounter Worksheets, power of attorney forms, or anything not captured in the Connect™ Platform
which would support the claim result.

General Billing Information


The following billing requirements apply to all OutcomesMTM covered services. See Documentation
Requirements for Billable Services on page six for delivery and documentation requirements for each MTM
opportunity.

• OutcomesMTM does not guarantee payment for services provided when the patient was not eligible.

• Each MTM claim is required to meet the minimum documentation and billing requirements outlined in this
guide and the Connect™ Platform in order to be eligible for payment. Claims missing required information or
that need clarification will be placed in Review & Resubmit status, if appropriate.

• OutcomesMTM shall compensate the MTM Center for the provision of MTM services in accordance with the
rates adjudicated within the Connect™ Platform upon claim approval. Under no circumstances shall
OutcomesMTM be required to compensate MTM Center for provision of MTM to any person who is not an
OutcomesMTM eligible patient.

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• When the change in therapy is verified in the patient’s prescription claims data provided by the health plan, a
validation payment may be made. The MTM claim’s validation status is determined 120 days following the
MTM service date. Validation payments may vary by health plan and are applicable for select plans. Only
medications that are processed via the patient’s prescription drug plan will be eligible for validation.

• Claims may only be billed for services in which a pharmacist intervention was made. If the pharmacist did not
perform an intervention that resulted in a medication change a claim cannot be billed. For example, if a
medication was discontinued prior to a pharmacist recommendation being made, no intervention was
performed by the pharmacist and a claim should not be billed, or in the instance of a TIP, the TIP should be
documented as No Intervention Needed.

Documentation Requirements for Billable Services


The billable services and documentation requirements listed below contain the interventions payable within
OutcomesMTM programs. Covered services vary by health plan and are patient-specific. To see which services
an OutcomesMTM eligible patient may receive, view the patient’s profile in the Connect™ Platform.

COMPREHENSIVE MEDICATION REVIEWS


A Comprehensive Medication Review (CMR) is an interactive, person-to-person consultation to complete a review
of the patient’s current medications (including prescriptions, over-the-counter (OTC) medications, herbal therapies
and dietary supplements) performed in real-time by a pharmacist; a summary of the review is required to be
provided to the patient in the CMS standardized format.

On average, CMRs provided in the OutcomesMTM program take 30 minutes to complete. All CMRs scheduled in
the Connect™ Platform should be scheduled for the time confirmed by both the patient and pharmacist. CMRs
that are scheduled without the patient’s knowledge are subject to cancellation. Although not required,
OutcomesMTM encourages pharmacists to provide the patient’s primary care provider with a copy of the Patient
Takeaway to maintain continuity of care.

Documentation Requirements
Needs CMR – Complex Drug Therapy (100) 1. Select the appropriate method of delivery – face-to-face, phone or telehealth
Comprehensive Medication Review (200) a. If phone is selected, a prior authorization code may be required (to
CMR – Drug Therapy Problems Identified (300) obtain a prior authorization code, contact OutcomesMTM in advance
OR of CMR delivery.)
Needs CMR – Complex Drug Therapy (100) b. In instances where a HIPAA-compliant video-conferencing
Comprehensive Medication Review (200) technology is utilized to provide the CMR, please document the
CMR – No Drug Therapy Problems Identified (301) method of delivery as telehealth
2. Review and update the patient’s Health Profile to include the following
information:
a. Current Conditions
b. Drug Allergies & Side Effects (include drug name and reaction)
3. Review and update the patient’s Medication List to include all current
prescription and non-prescription medications. Medication(s) must include:
a. Medication name and strength
b. Directions for use (quantity, form, route and frequency, in patient-
directed language)
c. Related Condition
d. Prescriber (for OTC medications use “self”)
4. Document each actionable item identified during the CMR on the Medication
Action Plan (MAP)
a. Include the following for each issue, in patient-directed language:
i. Description of the item
ii. What the patient should do
b. Arrange the actionable items/topics discussed in order of importance,
with the most important item(s) listed first
5. Date CMR was completed
6. Recipient of the CMR
a. If someone other than the patient, document the following:
i. Role of the CMR recipient (e.g., legally authorized
representative)
ii. Name of the CMR recipient
iii. Patient’s cognitive impairment status (yes/no). To
determine cognitive impairment status, utilize facility

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personnel, family members and any established
documentation to support the decision, where applicable.
iv. If the patient was determined to be cognitively impaired,
document how the determination was made
7. Pharmacist’s availability for questions
8. Where the Patient Takeaway should be sent
a. If the patient was the recipient of the CMR service, the Patient
Takeaway must be delivered to the patient.
b. If the takeaway should be sent to an address other than the patient’s
address, document the recipient’s name, address, city, state and ZIP
code.
c. If the patient is cognitively impaired, the takeaway should be sent to
the patient’s legally authorized representative. Document the legally
authorized representative’s name, address, city, state and ZIP code.
9. Select the language for the Patient Takeaway template (all information
entered by the user will appear in the language entered by the user)
10. Date of Patient Takeaway was delivery
11. Attest to reviewing the patient’s drug allergies & side effects, medications
and MAP and providing the CMR recipient with the exact Patient Takeaway
generated by the system (no substitutions)
12. Create the Patient Takeaway, print and deliver to the patient (or the recipient
of the CMR) within 7 days of the date the CMR was completed
13. Submit the CMR claim

NEEDS MEDICATION RECONCILIATON


A claim may be documented with the Needs Medication Reconciliation reason code when a patient has been
recently discharged from the hospital and is an appropriate candidate for a medication reconciliation. A
consultation with the patient/patient representative is necessary in order to reconcile all medications. Additionally,
a consultation with a prescriber or discharge facility may be necessary in order to obtain a discharge medication
list.

Medication reconciliation (MedRec) is the process of comparing a patient’s pre-admission medication list to the
discharge medication list in order to prevent or identify drug therapy problems. The MedRec service helps ensure
any changes made to the patient’s medication list are intentional based on the patient’s post-discharge care plan.
• Obtain discharge medication list from an appropriate source (e.g. patient, caregiver or health system).
• Compare the discharge medication list with the patient’s medications prior to hospitalization to determine
which medications should be stopped, started or continued. Consult the appropriate physicians when
necessary.
• Deliver Prescriber Summary to patient’s Primary Care Physician (PCP).
• Deliver Patient Summary to patient or caregiver. Counsel on which medications to start, stop or continue.
• Deliver Pharmacy Summary to applicable dispensing pharmacies (optional).

Documentation Requirements
Needs Medication Reconciliation (102) 1. Date of discharge
Medication Reconciliation (202) 2. Discharge facility
Completed Medication Reconciliation (302) 3. Review and update the patient’s current conditions and drug allergies/side effects
4. Reconcile the medications
a. Obtain the discharge medication list
b. Select where the discharge medication list was obtained
c. Indicate if each medication should be stopped, started, or continued
5. Attest that all stopped medication prescriptions have been deactivated in the
dispensing system
6. Indicate what was discussed with the patient/patient representative (select all that
apply)
7. Completion date of the Medication Reconciliation (Encounter Date)
8. Method of delivery
9. Recipient of the Medication Reconciliation (MedRec)
a. If someone other than the patient, document the following:
i. Role of the MedRec recipient (e.g., legally authorized
representative)

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ii. Name of the MedRec recipient
iii. Patient’s cognitive impairment status (yes/no). To determine
cognitive impairment status, utilize facility personnel, family
members and any established documentation to support the
decision, where applicable.
10. Primary Care Physician (PCP) Information
a. Does the patient have a PCP?
i. If yes, enter the PCP name, phone number and fax number
b. Is there an appointment with the PCP following discharge?
i. If yes, enter the date of the scheduled appointment (optional)
11. Review, print and deliver the Patient Summary generated by the OutcomesMTM
platform (no substitutions)
a. Document the date the summary was delivered to the patient
b. Select the recipient of the summary
c. Indicate the name and address of the recipient of the summary
d. Enter additional notes to be include in the summary (optional)
12. Review, print and deliver the PCP Summary generated by the OutcomesMTM
platform (no substitutions)
a. Document the date the summary was delivered to the PCP
b. Indicate the name, phone number and fax number of the PCP
c. Enter additional notes to be included in the summary (optional)
13. Review and deliver the Pharmacy Summary generated by the OutcomesMTM
platform (optional)
a. Document the date the summary was delivered to the pharmacy
b. Name, address, phone number and fax number of the pharmacy
c. Enter additional notes to be included in the summary (optional)

PRESCRIBER CONSULTATIONS
The following billable services require a consultation with the prescriber and communication with the patient
regarding any changes in medications.

Cost Effective Alternative


A claim may be documented with the Cost Effective Alternative reason code when a patient is identified as using
a higher cost drug product when there may be a cost-effective alternative available. A consultation with the
patient/patient representative and the prescriber is necessary to complete the change in medication regimen.

TIP Note: If the patient was already prescribed a more cost-effective alternative prior to TIP initiation or the patient
is not an appropriate candidate for the Cost-effective Alternative TIP, the TIP should be submitted as No
Intervention Needed.

Documentation Requirements
Cost Effective Alternative (105) 1. Confirmation the prescriber & patient agreed to the cost-effective alternative
Prescriber Consultation (205) 2. Confirmation the patient has a new, valid prescription for the cost-effective alternative
Initiated Cost Effective Drug (305) 3. Confirmation the prescription for the higher cost medication has been
deactivated/discontinued/closed
4. Date the outcome was determined
5. Initial prescription including quantity and days supply last prescribed
6. New prescription therapy including the quantity and days supply of the new prescription

NOTE: Dispensing an AB-rated generic equivalent when state law does not require a prescriber
consultation does not constitute a payable claim.
Cost Effective Alternative (105) 1. Confirmation the prescriber agreed the patient no longer needs the high cost medication
Prescriber Consultation (205) 2. Confirmation the prescription for the higher cost medication has been
Discontinued Therapy (335) deactivated/discontinued/closed
3. Date the outcome was determined
4. Initial prescription including quantity and days supply last prescribed
5. Patient-specific details about the steps that were taken to complete the intervention

Needs Drug Therapy


A claim may be documented with the Needs Drug Therapy reason code when a medication is needed for an
untreated indication. A consultation with the patient/patient representative and the prescriber is necessary in order
to initiate the change in medication regimen following a pharmacist recommendation.

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TIP Note: If a patient was already prescribed the needed medication prior to TIP initiation or the patient is not an
appropriate candidate for the Needs Drug Therapy TIP, the TIP should be submitted as No Intervention Needed.

Documentation Requirements
Needs Drug Therapy (120) 1. Date the outcome was determined
Prescriber Consultation (205) 2. New prescription therapy
Initiated New Therapy (330) 3. Severity level and patient-specific information that supports the severity level selected OR
Patient-specific details about the steps that were taken to complete the intervention

Needs Immunization
A claim may be documented with the Needs Immunization reason code when an immunization is indicated for the
patient. A consultation with the patient/patient representative following the pharmacist’s recommendation is
necessary in order to successfully administer the immunization. In some instances, a patient may elect to receive
the immunization from a physician office. This is acceptable as long as the immunization administration date is
verified and documented. Please note this intervention is documented as a prescriber consultation even when a
pharmacy has a standing protocol for the administration of immunizations. Some health plans require a
successful CMR claim within the last 12 months as a pre-requisite for a patient to be eligible for an immunization
MTM service.

TIP Note: If a patient has already received the recommended immunization or is not an ideal candidate for the
immunization, the Needs Immunization TIP should be submitted as No Intervention Needed.

Documentation Requirements
Needs Immunization (121) 1. Date immunization was administered
Prescriber Consultation (205) 2. Date the outcome was determined
Immunization Administered (331) a. This date cannot be greater than 30 days from the date the immunization was
administered
3. Immunization prescription information

Unnecessary Prescription Therapy


A claim may be documented with the Unnecessary Prescription reason code when a patient is prescribed a
medication that is not indicated. A consultation with the patient/patient representative and the prescriber is
necessary in order to initiate the discontinuation of a drug therapy following a pharmacist recommendation.

Documentation Requirements
Unnecessary Prescription Therapy (125) 1. Date the outcome was determined
Prescriber Consultation (205) 2. Unnecessary prescription including quantity and days supply last prescribed
Discontinued Therapy (335) 3. Severity level and patient-specific information that supports the severity level selected
OR Patient-specific details about the steps that were taken to complete the intervention

Suboptimal Drug
A claim may be documented with the Suboptimal Drug reason code when a patient is prescribed a medication
that is a suboptimal selection for the patient. A consultation with the patient/patient representative and the
prescriber is necessary in order to initiate the discontinuation of a drug therapy or change a drug therapy following
a pharmacist recommendation.

TIP Note: If a patient’s medication was already discontinued or changed prior to TIP initiation or the patient is not
an appropriate candidate for the Suboptimal Drug Selection TIP, the TIP should be submitted as No Intervention
Needed.

Documentation Requirements
Suboptimal Drug (130) 1. Date the outcome was determined
Prescriber Consultation (205) 2. Suboptimal prescription including quantity and days supply last prescribed
Discontinued Therapy (335) 3. Severity level and patient-specific information that supports the severity level selected OR Patient-
specific details about the steps that were taken to complete the intervention
Suboptimal Drug (130) 1. Date the outcome was determined
Prescriber Consultation (205) 2. Suboptimal prescription including quantity and days supply last prescribed
Changed Drug (340) 3. New prescription therapy including the quantity and days supply of the new prescription

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4. Severity level and patient-specific information that supports the severity level selected OR Patient-
specific details about the steps that were taken to complete the intervention

Dose Too Low


A claim may be documented with the Dose Too Low reason code when a patient is prescribed a medication at a
dose insufficient to be effective. A consultation with the patient/patient representative and the prescriber is
necessary in order to initiate the change in dose following a pharmacist recommendation.

Documentation Requirements
Dose Too Low (135) 1. Date the outcome was determined
Prescriber Consultation (205) 2. Initial prescription including quantity and days supply last prescribed
Increased Dose (345) 3. New prescription therapy including the quantity and days supply of the new prescription
4. Severity level and patient-specific information that supports the severity level selected OR Patient-
specific details about the steps that were taken to complete the intervention

Adverse Drug Reaction


A claim may be documented with the Adverse Drug Reaction reason code when a patient is prescribed a
medication with adverse reaction risk significant enough to render a drug therapy unsafe, including side effects
and allergic or idiosyncratic reactions. A consultation with the patient/patient representative and the prescriber is
necessary in order to initiate the discontinuation of drug therapy, decrease the dose or change a drug therapy
following a pharmacist recommendation.

Documentation Requirements
Adverse Drug Reaction (140) 1. Date the outcome was determined
Prescriber Consultation (205) 2. Prescription related to the adverse drug reaction including quantity and days supply last
Discontinued Therapy (335) prescribed
3. Severity level
4. Patient-specific information that supports the severity level selected
Adverse Drug Reaction (140) 1. Date the outcome was determined
Prescriber Consultation (205) 2. Prescription related to the adverse drug reaction including quantity and days supply last
Changed Drug (340) prescribed
3. New prescription therapy including the quantity and days supply of the new prescription
4. Severity level
5. Patient-specific information that supports the severity level selected
Adverse Drug Reaction (140) 1. Date the outcome was determined
Prescriber Consultation (205) 2. Prescription related to the adverse drug reaction including quantity and days supply last
Decreased Dose (355) prescribed
3. New prescription therapy including the quantity and days supply of the new prescription
4. Severity level
5. Patient-specific information that supports the severity level selected

Drug Interaction
A claim may be documented with the Drug Interaction reason code when a patient is prescribed two or more
medications with an interaction risk significant enough to render the regimen unsafe. A consultation with the
patient/patient representative and the prescriber is necessary in order to initiate the discontinuation of drug
therapy or a change in drug therapy following a pharmacist recommendation.

TIP Note: If a patient already received a medication regimen adjustment prior to TIP initiation or the patient is not
an appropriate candidate for the Drug Interaction TIP, the TIP should be submitted as No Intervention Needed.

Documentation Requirements
Drug Interaction (145) 1. Date the outcome was determined
Prescriber Consultation (205) 2. Prescription related to the drug interaction including quantity and days supply last prescribed
Discontinued Therapy (335) 3. Severity level and patient-specific information that supports the severity level selected OR
Patient-specific details about the steps that were taken to complete the intervention
Drug Interaction (145) 1. Date the outcome was determined
Prescriber Consultation (205) 2. Prescription related to the drug interaction including quantity and days supply last prescribed
Changed Drug (340) 3. New prescription therapy including the quantity and days supply of the new prescription
4. Severity level and patient-specific information that supports the severity level selected OR
Patient-specific details about the steps that were taken to complete the intervention
Drug Interaction (125) 1. Date the outcome was determined

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Prescriber Consultation (205) 2. Prescription related to the drug interaction including quantity and days supply last prescribed
Decreased Dose (355) 3. New prescription therapy including the quantity and days supply of the new prescription
4. Severity level and patient-specific information that supports the severity level selected OR
Patient-specific details about the steps that were taken to complete the intervention

Dose Too High


A claim may be documented with the Dose Too High reason code when a patient is prescribed a medication at a
dose too excessive to be safe. A consultation with the patient/patient representative and the prescriber is
necessary in order to initiate the decrease in dose of the drug therapy or a change in drug therapy following a
pharmacist recommendation.

Documentation Requirements
Dose Too High (150) 1. Date the outcome was determined
Prescriber Consultation (205) 2. Initial prescription including quantity and days supply last prescribed
Decreased Dose (355) 3. New prescription therapy including the quantity and days supply of the new prescription
4. Severity level and patient-specific information that supports the severity level selected OR Patient-
specific details about the steps that were taken to complete the intervention
Dose Too High (150) 1. Date the outcome was determined
Prescriber Consultation (205) 2. Initial prescription including quantity and days supply last prescribed
Changed Drug (340) 3. New prescription therapy including the quantity and days supply of the new prescription
4. Severity level and patient-specific information that supports the severity level selected OR Patient-
specific details about the steps that were taken to complete the intervention

PATIENT ADHERENCE CONSULTATIONS


The following billable services require a consultation with the patient/patient representative, at a minimum, in
order to successfully complete the intervention.

Needs Medication Synchronization


A claim may be documented with the Needs Medication Synchronization reason code when a patient is an
appropriate candidate for having his/her medications synchronized to a common fill date. A consultation with the
patient/patient representative is necessary in order to successfully synchronize his/her medications. Medications
being synced must be dispensed by the documenting pharmacy.

TIP Note: For a Needs Medication Synchronization TIP, if the patient’s medications are already synchronized or
the patient is not an appropriate candidate for synchronization the TIP should be submitted as No Intervention
Needed.

Documentation Requirements
Needs Medication Synchronization (122) MEDSYNC ADVANTAGE TOOL
Patient Consultation (215) 1. Medication synchronization date
Medications Synchronized (332) a. Select the first date all medications will be refilled together
2. Medications that will be synchronized
a. At least two synced medications are required and one must be a Star
medication
3. Indicate Sync by checking the box for those medications to be filled on a common date
moving forward
a. To add a medication from another pharmacy to the MedSync Plan obtain the
patient’s approval to transfer the medication and receive the new
prescription
4. Indicate Don’t Sync for those medications that will not be filled on a common date

NOTE: The MedSync Advantage tool is only available for select health plans and is accessible
for users with Internet Explorer version 9 or higher, Firefox or Chrome browsers.
Needs Medication Synchronization (122) MANUAL MEDSYNC DOCUMENTATION
Patient Consultation (215) 1. Date you created the medication synchronization plan (Encounter Date)
Medications Synchronized (332) 2. Medication synchronization date
a. Select the first date all medications will be refilled together
3. Medications that will be synchronized
a. At least two synced medications are required and one must be a Star
medication
4. The quantity, days supply and fill date for the next medication fill

Needs Medication Assessment


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A claim may be documented with the Needs Medication Assessment reason code when a patient is using a
medication with a high risk for adverse events. A consultation with the patient/patient representative is necessary
in order to complete a medication assessment that evaluates the present of an adverse event(s).

TIP Note: For a Needs Medication Assessment TIP, if the patient is no longer using the targeted medication or is
not an appropriate candidate the TIP should be submitted as No Intervention

Documentation Requirements
Needs Medication Assessment (124) 1. Attestation that the patient was provided the education outlined in the TIP
Patient Consultation (215) overview
Assessment completed – No issues identified (324) 2. Complete the following Yes/No questions:
a. Did the patient report any adverse events?
b. Is the patient’s relevant disease state controlled? (i.e. INR is within
goal range)
3. Date the outcome was determined
Needs Medication Assessment (124) 1. Attestation that the patient was provided the education outlined in the TIP
Patient Consultation (215) overview
Assessment completed – Issues identified (325) 2. Complete the following Yes/No questions:
a. Did the patient report any adverse events?
b. Is the patient’s relevant disease state controlled? (i.e. INR is within
goal range)
3. Date the outcome was determined

Needs Lab Monitoring or Health Test


A claim may be documented with the Needs Lab Monitoring or Health Test reason code when a patient is in need
of a lab or screening. A consultation with the patient/patient representative is necessary in order to administer the
lab or screening.

TIP Note: For a Needs Lab Monitoring or Health Test TIP, if the patient has already received the lab or screening
or is not an appropriate candidate the TIP should be submitted as No Intervention Needed.

Documentation Requirements
Needs Lab Monitoring or Health Test(126) 1. Date Lab/Health test administered
Patient Consultation (215) 2. Lab/Health test value
Completed Lab Monitoring or Health Test (326) 3. Name of primary care provider
4. Date the outcome was determined

Adherence - Overuse of Medication


A claim may be documented with the Adherence - Overuse of Medication reason code when a patient has a
demonstrated overuse of a drug product and as a result is non-adherent. An initial and follow-up consultation with
the patient/patient representative is necessary in order to alter the patient’s behavior to become adherent to the
drug therapy.

Documentation Requirements
Adherence – Overuse of Medication (155) 1. Date of initial adherence consultation
Patient Consultation (215) 2. Date of follow-up (must be at least 14 days after the initial consultation and must
Altered Adherence (360) include refill verification)
3. Attestation that the patient reported improved adherence upon follow-up
4. Prescription information
5. Severity level
6. Patient-specific information that supports the severity level selected

Adherence – Underuse of Medication


A claim may be documented with the Adherence – Underuse of Medication reason code when a patient has a
demonstrated underuse (>6 days missed in a 30-day supply/>18 days missed in a 90-day supply) of a drug
product and as a result is non-adherent. An initial and follow-up consultation with the patient/patient
representative is necessary in order to alter the patient’s behavior to become adherent to the drug therapy.

Documentation Requirements
Adherence – Underuse of Medication (160) 1. Date of initial adherence consultation
Patient Consultation (215)

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Altered Adherence (360) 2. Date of follow-up (must be at least 14 days after the initial consultation and must
include refill verification)
3. Attestation that the patient picked up the next refill on time (within 6 days for a 30
day dispense supply or within 18 days for a 90 day dispensed supply)
a. The on-time refill must be after the date the non-adherence was
identified but cannot be the same day
4. Attestation that the patient reported improved adherence upon follow-up
5. Barriers to adherence (select all that apply)
6. Solutions to identified barriers to adherence (select all that apply; at least one
solution per barrier is required)
7. Prescription information
8. Severity level
9. Patient-specific information that supports the severity level selected

Needs Refill
A claim may be documented with the Needs Refill reason code when a patient is in need for a medication refill. A
consultation with the patient/patient representative and a refilled medication is necessary in order to complete this
service.

TIP Note: If the patient is no longer taking the targeted medication, has already refilled the medication or is not an
appropriate candidate for the TIP, the Needs Refill TIP should be submitted as No Intervention Needed.

Documentation Requirements
Needs Refill (163) 1. Attestation that the medication refill occurred
Patient Consultation (215) 2. Confirmation the patient will pick up the medication
Patient Refilled Rx (363) 3. Date the outcome was determined
4. Prescription information

Adherence – Inappropriate Admin/Technique


A claim may be documented with the Adherence – Inappropriate Administration/Technique reason code when a
patient has demonstrated inappropriate administration technique of a drug product that has negatively affected
the outcome of therapy. An initial and follow-up consultation with the patient/patient representative and a follow-up
check is necessary in order to alter the patient’s behavior to become adherent to the drug therapy.

Documentation Requirements
Adherence – Inappropriate Admin/Technique (165) 1. Date of initial adherence consultation
Patient Consultation (215) 2. Date of follow-up (must be at least 14 days after the initial
Altered Administration or Technique (365) consultation)
3. Attestation that the patient reported improved adherence upon follow-
up
4. Prescription information
5. Severity level
6. Patient-specific information that supports the severity level selected

Adherence – Needs Check-in


A claim may be documented with the Adherence – Needs Check-in reason code when a patient may or may not
be adherent to his/her medication but could benefit from additional education about the medication, assistance on
ways to overcome existing adherence barriers or potential barriers and reinforcement of the importance of
adherence to the medication. A consultation with the patient/patient representative is necessary in order to
educate, assist and reinforce medication adherence.

TIP Note: If the patient is no longer using the medication or a medication in the same drug class the Adherence-
Needs Check-in TIP should be submitted as No Intervention Needed.

Documentation Requirements
Adherence – Needs Check-in (171) 1. Date the outcome was determined
Patient Consultation (215) 2. Barriers to adherence (select all that apply)
Adherence Check-in Completed (371) 3. Solutions to identified barriers to adherence (select all that apply; at least one solution
per barrier is required)
4. Prescription information

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Adherence – Needs Check-in + 90-day Fill
A claim may be documented with the Adherence – Needs Check-in + 90-day Fill reason code when a patient may
or may not be adherence to his/her medication but could benefit from a 90-day supply of the medication. A
consultation with the patient/patient representative is necessary in order to provide additional education about the
medication, assist on ways to overcome existing adherence barriers or potential barriers, reinforce the importance
of adherence to the medication and transition to a 90-day supply of the medication. In some instances, a
consultation with the prescriber may also be necessary in order to obtain a prescription for a 90-day medication
supply.

TIP Note: If the patient is no longer using the medication or a medication in the same drug class the Adherence-
Needs Check-in + 90-day Fill TIP should be submitted as No Intervention Needed. Selection of result code
Adherence Check-in Completed + 90-day Fill indicates the patient is agreeable to transitioning to a 90-day supply
of the medication and an updated prescription has been obtained from the prescriber for a 90-day supply, where
necessary.

Documentation Requirements
Adherence – Needs Check-in + 90-day Fill (172) 1. Confirmation the patient agreed to the 90-day fill
Patient Consultation (215) 2. Confirmation the patient’s prescription is written to allow a 90-day fill
Adherence Check-in Completed + 90-day Fill (372) 3. Date the outcome was determined
4. Barriers to adherence (select all that apply)
5. Solutions to identified barriers to adherence (select all that apply; at least
one solution per barrier is required)
6. Prescription information

Adherence Monitoring
The Adherence Monitoring Program aims to improve and/or maintain adherence to targeted medications.
OutcomesMTM identifies select patients for the program and prompts pharmacists to monitor patient adherence
to targeted medications at least quarterly by documenting an Adherence Monitoring Checkpoint.

Once a pharmacy has completed the Adherence Monitoring TIP, the pharmacy that enrolled the patient is
accountable for the patient’s adherence to the targeted medication for the remainder of the calendar year. If all
checkpoints are documented and the patient achieves or exceeds the target adherence rate, the pharmacy is
eligible for a year-end bonus. Bonus payments vary by health plan.

A claim may be documented with the Adherence Monitoring reason code when a patient who may or may not be
adherent to his/her medication could benefit from the Adherence Monitoring Program. A consultation with the
patient/patient representative is necessary in order to provide additional education about the medication, assist on
ways to overcome existing adherence barriers or potential barriers and reinforce the importance of adherence to
the medication. Selection of result code Patient Monitored & Enrolled indicates the pharmacist consulted with the
patient/patient representative and addressed barriers to adherence or encouraged the patient to maintain
adherence, enrolling the patient into the Adherence Monitoring Program.

TIP Note: If the patient is no longer using the medication or a medication in the same drug class, the Adherence
Monitoring TIP should be submitted as No Intervention Needed.

Documentation Requirements
Adherence Monitoring (173) 1. Date the outcome was determined
Patient Consultation (215) 2. Barriers to adherence (select all that apply)
Patient Monitored & Enrolled (373) 3. Solutions to identified barriers to adherence (select all that apply; at least one solution
per barrier is required)
4. Prescription information

Adherence – Needs Monitoring


A claim may be documented with the Adherence – Needs Monitoring reason code when a patient is enrolled in
the Adherence Monitoring Program and requires another adherence focused consultation. These opportunities
are available from the Connect™ Platform Dashboard under the Adherence Monitoring queue. A consultation with
the patient/patient representative is necessary in order to provide additional education about the medication,
assist on ways to overcome existing adherence barriers or potential barriers and reinforce the importance of

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adherence to the medication. Selection of result code Monitoring Checkpoint Complete indicates the pharmacist
consulted with the patient/patient representative and addressed barriers to adherence and/or encouraged the
patient to maintain adherence.

Documentation Requirements
Adherence – Needs Monitoring (174) 1. Date the outcome was determined
Patient Consultation (215) 2. Prescription information
Monitoring Checkpoint Complete (374)

PATIENT EDUCATION & MONITORING


The following billable services require a consultation with the patient/patient representative, at a minimum, in
order to successfully complete the intervention.

New or Changed Prescription Therapy


A claim may be documented with the New or Changed Prescription Therapy reason code when a patient has an
order to initiate a new or changed prescription therapy. An initial and follow-up consultation with the patient/patient
representative is necessary in order to provide medication counseling and follow-up monitoring. All claims with a
reason code of New or Changed Prescription Therapy for which the prescription information submitted with the
claim cannot be validated via prescription claims data as a “new or changed” therapy for the patient will be
rejected.

Documentation Requirements
New or Changed Prescription Therapy (110) 1. Initial consultation date
Patient Education and Monitoring (210) 2. Follow-up date when the outcomes was determined
Therapy Success (310) 3. Complete the following Yes/No questions:
OR a. Is the patient satisfied with the therapy?
New or Changed Prescription Therapy (110) b. Did the symptoms improve?
Patient Education and Monitoring (210) c. Were any adverse reactions reported?
Therapy Failure (320) d. Is the patient adherent with therapy?
4. Prescription information

Needs Patient Education


A claim may be documented with the Needs Patient Education reason code when a patient is in need of
additional targeted education. A consultation with the patient/patient representative is necessary in order to
provide the additional education.

TIP Note: If the patient is not a good candidate for the focused education, the TIP should be submitted as No
Intervention Needed.

Documentation Requirements
Needs Patient Education (114) 1. Attestation that the patient was provided the education outlined in the TIP overview
Patient Education (214) 2. Date the outcome was determined
Patient Education Provided (314) 3. Patient-specific details about the steps that were taken to complete the intervention

New or Changed OTC Therapy


A claim may be documented with the New or Changed OTC Therapy reason code when a patient has an
untreated indication that requires an over-the-counter therapy. An initial and follow-up consultation with the
patient/patient representative is necessary in order to provide medication counseling and follow-up monitoring. All
claims for medications not classified as Rx-only or that are available over-the-counter are required to be
submitted with a reason code of New or Changed OTC Therapy. OTC therapy recommendations are required to
have evidence-based and patient-specific clinical rationale, including documented deficiencies and/or patient
symptoms, which is subject to quality assurance.

Documentation Requirements
New or Changed OTC Therapy (117) 1. Initial consultation date
Patient Education and Monitoring (210) 2. Follow-up date when the outcomes was determined
Therapy Success (310) 3. Complete the following Yes/No questions:
OR a. Is the patient satisfied with the therapy?

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New or Changed OTC Therapy (117) b. Did the symptoms improve?
Patient Education and Monitoring (210) c. Were any adverse reactions reported?
Therapy Failure (320) d. Is the patient adherent with therapy?
4. Therapy information
5. Severity level
6. Patient-specific information that supports the severity level selected OR Patient-
specific details about the steps that were taken to complete the intervention

Needs Pregnancy Test


A claim may be documented with the Needs Pregnancy Test reason code when a female patient seeks a
pregnancy test. A consultation with the patient/patient representative is necessary in order to provide education
and counseling to the female patient.

Documentation Requirements
Needs Pregnancy Test (127) 1. Attestation that the patient was counseled to see doctor immediately in the case
Patient Education & Monitoring (210) of a positive pregnancy test
Provided Pregnancy Test and Counseling (327) 2. Attestation that the patient was counseled regarding the importance of prenatal
vitamins
3. Attestation that the patient’s medications were reviewed for any that should be
avoided in pregnancy
4. Attestation that the patient was questioned about hepatitis B vaccine series
5. Date the outcome was determined
6. Prescription information

Needs Follow-up for Pregnancy Test


A claim may be documented with the Needs Follow-up for Pregnancy Test reason code when a female patient
who previously sought a pregnancy test needs a follow-up consultation. A consultation with the patient/patient
representative is necessary in order to obtain the result of the pregnancy test and offer additional education as
applicable.

Documentation Requirements
Needs Follow-up for Pregnancy Test (128) 1. Result of pregnancy test
Patient Education & Monitoring (210) 2. Date outcome was determined
Completed Pregnancy Test Follow-up (328)

Needs Case Management


A claim may be documented with the Needs Case Management reason code when a patient could benefit from
one-on-one help to coordinate his/her healthcare needs through the patient’s health plan case management
program. A consultation with the patient is necessary in order to make a patient referral.

Documentation Requirements
Needs Case Management (123) 1. Date outcome was determined
Case Management Referral (207) 2. Reason for intervention (add to Additional Notes)
Patient referred (323) 3. Is the member phone number accurate? (add to Additional Notes)
a. If yes, note the phone number is accurate (Do not detail the patient’s
phone number within the claim)
b. If no, note that the phone number is not accurate for member and
document your pharmacy’s phone number after ensuring the member’s
phone number is accurate in your dispensing software

REFUSALS AND THREE ATTEMPTS UNABLE TO REACH


Patient
A claim may be documented with a Patient Refused result code when a patient refuses a consultation with the
pharmacist and/or a recommendation to change a medication. A claim may be documented with an Unable to
Reach Patient After 3 Attempts result code when a patient was unable to be reached after three attempts on three
separate days/times.

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Documentation Requirements
Comprehensive Medication Review (200) 1. Reason the patient refused the recommendation
Patient Refused (380) 2. Date the patient refused the recommendation
OR 3. Date of discharge (if applicable)
Medication Reconciliation (202)
Patient Refused (380)
OR
Patient Education and Monitoring (210)
Patient Refused (380)
OR
Patient Education (214)
Patient Refused (380)
OR
Patient Consultation (215)
Patient Refused (380)
Comprehensive Medication Review (200) 1. Date of the last attempt to reach the patient (after at least three unsuccessful
Unable to Reach Patient After 3 Attempts (379) attempts)
OR
Medication Reconciliation (202)
Unable to Reach Patient After 3 Attempts (379)
OR
Patient Education & Monitoring (210)
Unable to Reach Patient After 3 Attempts (379)
OR
Patient Education (214)
Unable to Reach Patient After 3 Attempts (379)
OR
Patient Consultation (215)
Unable to Reach Patient After 3 Attempts (379)

Prescriber
A claim may be documented with a Prescriber Refused Recommendation result code when a prescriber refuses a
consultation with the pharmacist and/or a recommendation to change a medication. A claim may be documented
with an Unable to Reach Prescriber After 3 Attempts result code when the prescriber was unable to be reached
after three attempts on three separate days/times.

Documentation Requirements
Prescriber Consultation (205) 1. Reason the prescriber refused the recommendation
Prescriber Refused Recommendation (375) 2. Date the prescriber refused the recommendation
3. Medication(s) related to the intervention
4. Prescriber NPI
Prescriber Consultation (205) 1. Date of the last attempt to reach the prescriber (after at least three
Unable to Reach Prescriber After 3 Attempts (378) unsuccessful attempts)
2. Medication(s) related to the intervention
3. Prescriber NPI

NO INTERVENTION NEEDED
A TIP may be marked as No Intervention Needed if at least one of the below circumstances is known or
discovered during the pharmacist’s execution of the TIP.

Documentation Requirements
No Intervention Needed 1. Select the reason why no intervention was needed (as applicable by reason
code):
a. Patient is no longer on medication
b. Patient was in hospital (or other transition of care)
c. Patient resides in a facility (LTC, assisted living, hospice, etc.)
d. Patient had adverse event/allergy to suggested medication
e. Patient has tried and failed suggested medication
f. Patient is deceased
g. Patient paid cash
h. Patient received samples
i. Patient is pill-splitting
j. Intervention already occurred
k. Prescriber lowered dose
l. Patient obtained medication from an outside source

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m. Patient is adherent
n. Patient is already taking the medication
o. Patient is no longer on medication in targeted drug class
p. Prescriber has already been consulted
q. Recommended therapy is not appropriate for patient
r. Directions written to take "as needed"
s. Unable to obtain discharge Medication List
t. Patient was readmitted to the hospital

Auditing and Monitoring


Quality Assurance
OutcomesMTM performs quality assurance (QA) checks to ensure that MTM claims are documented according to
the established policies and procedures outlined within this document and the Connect™ Platform and that the
severity level assigned to each MTM claim is reasonable and foreseeable based on the supporting documentation
provided. Supporting documentation provided in the Additional Notes field will be utilized for quality assurance
purposes.
The status of an MTM claim indicates where the claim is within the claim submission, quality assurance and
payment processes. The Connect™ Platform accommodates the following claim status categories:
Claim Status Categories
• Unfinished: indicates the claim is still in progress by the MTM Provider. Pharmacists have 60 days to
complete any unfinished claim (120 days for Adherence Underuse claims).
• Pending Approval: indicates the claim has been submitted by the MTM Provider and awaits quality
assurance review
• Review & Resubmit: indicates the claim has been submitted by the MTM Provider and has been
reviewed but is incomplete and requires further attention by the MTM Provider
• Rejected: indicates the claim has been submitted by the MTM Provider and did not pass quality
assurance review; the claim cannot be approved for payment
• Approved, Pending Payment: indicates the claim has been submitted by the MTM Provider and has
been approved for payment, but payment has not yet been processed
• Approved & Paid: indicates the claim has been submitted by the MTM Provider, passed quality
assurance review and payment has been processed

Claims left in Review & Resubmit status for longer than 30 days will be rejected. Claims left unfinished for longer
than 60 days (120 days for Adherence-Underuse claims) will be deleted. Claims that are resubmitted twice without
addressing the claim deficiency noted within the administrative note will be rejected. Pharmacists have 30 days to
dispute rejected claims from the date the claim was put in rejected status.

Fraud, Waste and Abuse


The detection and resolution of drug therapy problems is central to OutcomesMTM programs. Therefore,
OutcomesMTM assigns each pharmacy a Quality Assurance Zone to prevent fraud, waste and abuse. These
zones are designed to identify pharmacies whose activity is atypical in OutcomesMTM programs.

• Red Zone: The MTM Center has submitted a disproportionate number of unsuccessful and/or Patient
Education and Monitoring claims, without subsequent documentation of resolved drug therapy problems.
The MTM Center is unable to document these types of claims until the pharmacy’s claims are brought
back into balance.
• Yellow Zone: The MTM Center is beginning to reflect a disproportionate number of unsuccessful and/or
Patient Education and Monitoring claims, without subsequent documentation of resolved drug therapy
problems. The MTM Center is alerted via the platform dashboard to bring the pharmacy’s claims back into
balance. To do so, the MTM Center must document any successful patient adherence consultation,
prescriber consultation or CMR.
• Green Zone: The MTM Center is demonstrating typical claim activity. MTM Centers in the Green Zone
will not see any notification of this zone in the platform.

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Resolving QA Issues
If a QA reviewer identifies an issue with a claim, the claim is placed in Review & Resubmit status with an
administrative note from the reviewer. Claims in Review & Resubmit status are highlighted on the user’s
dashboard when he/she logs into the Connect Platform. Pharmacists are allowed to correct and resubmit MTM
claims that have not initially passed the quality assurance process. If unresolved QA issues persist, an
OutcomesMTM Quality Assurance representative will contact the participating MTM Center/MTM Center
personnel to provide interactive feedback to resolve the QA issues, or to establish a Corrective Action Plan.

Corrective Action
OutcomesMTM utilizes various systems to audit and monitor MTM Providers to detect Fraud, Waste, and Abuse.
When a MTM Provider is identified as an outlier, OutcomesMTM performs the following actions to evaluate the
MTM Provider.

1. The MTM Provider is contacted by a representative of the Quality Assurance department to discuss
the service(s) performed. The QA representative will determine if the provider submitted the claim(s)
in question with intention or as a result of miseducation.
2. Following the discussion with the MTM Provider, the claim(s) in question will be moved to the
appropriate status, including Rejected status, if necessary.
3. The MTM Provider will be monitored on a regular basis by the QA department for a period of 3
months.

OutcomesMTM reserves the right to restrict MTM Provider access for completing and documenting MTM services
to eligible members at any time, as necessary.

Compliance and Regulation


An MTM Center is required to notify OutcomesMTM if it does not meet any of the below requirements. MTM
Center’s network status is subject to approval by OutcomesMTM.
Applicable Laws and Regulations
The Centers for Medicare & Medicaid Services (CMS) mandate that plan sponsors administering a Medicare
Advantage program or Medicare Part D prescription drug plan implement an effective compliance program that
meets the regulatory requirements set forth in 42 C.F.R. §422.503(b)(4)(vi) and 42 C.F.R. §423.504(b)(4)(vi). As
an entity with direct contractual relationships with Medicare Advantage Plans and Medicare Part D prescription
drug plans, OutcomesMTM is obligated to ensure that its downstream entities performing Medicare Advantage or
Medicare Part D services are compliant with all applicable laws, including having policies and procedures in place
to prevent fraud, waste and abuse, avoid conflicts of interest and train employees on applicable Medicare laws,
rules, regulations and CMS guidance.
Each MTM Center warrants (and agrees to attest upon OutcomesMTM’s request) the following, with respect to
any provision of MTM to Medicare beneficiaries:
• MTM Center’s MTM Providers, governing body members, officers and directors complete HIPAA/HITECH
training within the first ninety (90) days of employment/contracting and annually thereafter;
• MTM Center’s MTM Providers, governing body members, officers and directors complete the
standardized general CMS compliance and Fraud, Waste and Abuse (FWA) training and education
module developed by the Centers for Medicare & Medicaid Services (CMS) within the first ninety (90)
days of employment/contracting and annually thereafter;
• MTM Center has adopted an effective compliance program, which includes, at a minimum, written
policies, procedures and standards of conduct that articulate the MTM Center’s commitment to comply
with all applicable federal and state laws; a conflict of interest reporting and review process; designation
of a compliance officer and compliance committee; a process to communicate compliance related
requirements to MTM Providers, governing body members, officers and directors; a process for
individuals and downstream entities to report suspected FWA and compliance issues; a policy that
protects individuals and downstream entities from retaliation when reporting suspected compliance and

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FWA issues; widely publicized disciplinary standards; a process for identifying and monitoring compliance
and FWA risks; and a policy requiring prompt response and correction to detected compliance issues;
• MTM Center has implemented policies and procedures to document the review of the Office of Inspector
General (OIG), General Services Administration (GSA) and Systems Award Management (SAM)
exclusion lists prior to initial hire/contracting and monthly thereafter to ensure that all of the MTM Center’s
downstream entities (including their employees, officers and governing body directors) and MTM Center
employees, including managers, officers, and governing body directors responsible for administering or
delivering Medicare Part D or Medicare Advantage services are not excluded from participating in
federally funded healthcare programs according to the OIG and GSA exclusion lists. MTM Center further
warrants that it will promptly remove from providing such services on behalf of OutcomesMTM any of
MTM Center’s MTM Providers or employees and/or any of MTM Center’s downstream entities or their
employees that are excluded from participating in federally funded healthcare programs according to
these exclusion lists;
• MTM Center (including MTM Center’s employees and MTM Providers performing Part D or Medicare
Advantage services relative to a Part D Plan Sponsor or Medicare Advantage Organization) agrees to
read and comply with any written compliance policies and procedures and standards of conduct made
available by OutcomesMTM or comparable policies, procedures or standards of conduct of its own that
meet applicable CMS requirements;
• MTM Center has implemented written record retention policies and procedures to ensure that any
documents, books and records that substantiate compliance with this attestation or related to Entity’s
performance of its obligations as a provider of Medicare Part D or Medicare Advantage services are
retained for a period of at least ten (10) years and MTM Center will provide CMS, or its designee, with
access to such records if requested; and
• MTM Center warrants that neither MTM Center nor any downstream or related entity utilized by MTM
Center to provide MTM to Medicare beneficiaries on behalf of OutcomesMTM utilizes an offshore vendor
and/or subcontractor to provide said services. MTM Center further attests that neither MTM Center nor
any downstream or related entity utilized by MTM Center provides protected health information or PHI (as
such term is defined at 45 C.F.R. §160.103) of a Medicare beneficiary to any offshore vendor and/or
subcontractor. For the purposes of this attestation, the term “offshore” shall refer to any country that is not
one of the fifty United States or one of the following United States Territories: American Samoa, Guam,
Northern Marianas, Puerto Rico and the Virgin Islands.

Kansas Medicaid Immigration Reform and Control Requirements


• MTM Center is expected to comply with the Immigration and Reform Control Act of 1986 (IRCA), as may
be amended from time to time. This Act, with certain limitations, requires the verification of the
employment status of all individuals who were hired on or after November 6, 1986, by MTM Center.

• MTM Center hereby certifies without exception that MTM Center has complied with all federal and state
laws relating to immigration and reform. Any misrepresentation in this regard or any employment of
persons not authorized to work in the United States constitutes a material breach and, at the State’s
option, may subject the contract to termination and any applicable damages.

• MTM Center will comply with all applicable federal and state laws, standards, orders and regulations
affecting a person’s participation and eligibility in any program or activity undertaken by MTM Center
pursuant to the MTM Network Participation Agreement (“Agreement”) for services provided under Kansas
Medicaid Contract. MTM Center further certifies that it will remain in compliance throughout the term of
the Agreement.

At OutcomesMTM or the State’s request, MTM Center is expected to produce to Outcomes and/or the State any
documentation or other such evidence to verify MTM Center’s compliance with any provision, duty, certification, or
the like under the Agreement.

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Appendix A. Glossary of Terms
Action: The professional service associated with an OutcomesMTM claim.

Adherence – Needs Check-in (171): Indication for Service (Reason) code


Applies to a TIP generated by OutcomesMTM for a patient taking a medication for which adherence is important
to the health plan. The patient may or may not be adherent to the medication at the time of TIP generation. The
intervention should be tailored to the patient but primarily involve educating about the medication, overcoming
existing or potential barriers to adherence and reinforcing the importance of adherence.

Adherence – Needs Check-in + 90-day Fill (172): Indication for Service (Reason) code
Applies to a TIP generated by OutcomesMTM for a patient taking a medication for which adherence is important
to the health plan and is eligible for a 90-day supply. The patient may or may not be adherent to the medication at
the time of TIP generation. The intervention should include offering to transition the patient to a 90-day supply as
well as educating about the medication, overcoming existing or potential barriers to adherence and reinforcing the
importance of adherence.

Adherence – Inappropriate Admin/Technique (165): Indication for Service (Reason) code


Applies to the presentation of a patient who has demonstrated inappropriate administration technique of a drug
product that has negatively affected the outcome of therapy.

Adherence – Needs checkpoint (174): Indication for Service (Reason) code


Applies to an Adherence Monitoring Checkpoint generated by OutcomesMTM for a patient enrolled in the
Adherence Monitoring Program because he/she takes a medication for which adherence is important to the health
plan. The patient may or may not be adherent to the medication at the time a checkpoint is due. The intervention
should be tailored to the patient and should include overcoming existing or potential barriers to adherence and
reinforcing the importance of adherence.

Adherence - Overuse of Medication (155): Indication for Service (Reason) code


Applies to the presentation of a patient who has demonstrated overuse of a drug product and as a result is non-
adherent.

Adherence - Underuse of Medication (160): Indication for Service (Reason) code


Applies to the presentation of a patient who has demonstrated underuse (>6 days missed in a 30-day supply/>18
days missed in a 90-day supply) of a drug product and as a result is non-adherent.

Adherence Check-in Completed (371): Outcome of Service (Result) code


Applies to completion of an Adherence Check-in with the patient/patient representative, during which medication
education was provided with an emphasis on the importance of adherence.

Adherence Check-in Completed + 90-day Fill (372): Outcome of Service (Result) code
Applies to completion of an Adherence Check-in with the patient/patient representative, during which medication
education was provided with an emphasis on the importance to adherence. In addition, the patient is agreeable to
transitioning to a 90-day supply of the medication and the pharmacist has obtained an updated prescription from
the prescriber for a 90-day supply.

Adherence Monitoring (173): Indication for Service (Reason) code


Applies to a TIP generated by OutcomesMTM for a patient who is taking a medication for which adherence is
important to the health plan. Successful completion of this TIP enrolls the patient into the Adherence Monitoring
Program. The patient may or may not be adherent to the medication at the time of TIP generation. The
intervention should be tailored to the patient but primarily involve educating about the medication, overcoming
existing or potential barriers to adherence and reinforcing the importance of adherence.

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Altered Adherence (360): Outcome of Service (Result) code
Applies to altering a patient’s behavior to become adherent to a drug therapy to which the patient was overusing
or underusing previously.

Altered Administration or Technique (365): Outcome of Service (Result) code


Applies to altering a patient’s behavior to become adherent to a drug therapy to which the patient previously
administered with inappropriate technique.

Adverse Drug Reaction (140): Indication for Service (Reason) code


Applies to the presentation of a drug therapy with an adverse reaction risk significant enough to render the
therapy unsafe, including side effects and allergic or idiosyncratic reactions.

Assessment Completed – Issues Identified (325): Outcomes of Service (Result) code


Applies to the completion of a medication assessment where an adverse event(s) is identified.

Assessment Completed – No issues identified (324): Outcome of Service (Result) code


Applies to the completion of a medication assessment where an adverse event(s) is not identified.

Case Management Referral (207): Service Provided (Action) Code


Applies to the referral of a patient for case management.

Changed Drug (340): Outcome of Service (Result) code


Applies to prescriber approval of a pharmacist recommendation to change a drug therapy that has suboptimal
efficacy.

CMR – Drug Therapy Problems Identified (300): Outcome of Service (Result) code
Applies to completion of a Comprehensive Medication Review that results in at least one additional intervention to
address a cost-efficacy issue or a drug therapy problem.

CMR – No Drug Therapy Problems Identified (301): Outcome of Service (Result) code
Applies to completion of a Comprehensive Medication Review that does not result in an additional intervention to
address a cost-efficacy issue or a drug therapy problem.

CMR - Complex Drug Therapy (100): Typically applies to the presentation of a patient taking three or more
medications.

Completed Lab Monitoring or Health Test (326): Outcome of Service (Result) code
Applies to completion of the health test outlined in the TIP overview. Applicable for select health plans.

Completed Medication Reconciliation (302): Outcomes of the Service (Result) code


Applies to the completion of a reconciliation of a patient’s medications as a result of him/her being discharged
from a hospital.

Completed Pregnancy Test Follow-up (328): Outcome of Service (Result) code


Applies to completion of follow-up counseling for a female patient who sought a pregnancy test. Applicable for
select health plans.

Comprehensive Medication Review (CMR) (200): Service Provided (Action) Code


Applies to a comprehensive review of a patient’s drug profile to identify any cost-efficacy issues or drug therapy
problems.

Cost-Effective Alternative (105): Indication for Service (Reason) code


Applies to the presentation of an order for a drug product for which a more cost-effective therapeutic alternative is
available.

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Date the Outcome Was Determined: References the date the result of an MTM intervention was determined.
Also referred to as Encounter Date.

Decreased Dose (355): Outcome of Service (Result) code


Applies to prescriber approval of a pharmacist recommendation to change a drug therapy for a dose or duration
too excessive to be safe.

Discontinued Therapy (335): Outcome of Service (Result) code


Applies to prescriber approval of a pharmacist recommendation to discontinue a drug therapy that is not indicated.

Dose Too High (150): Indication for Service (Reason) code


Applies to the presentation of an order to initiate or continue drug therapy at a dose or duration too excessive to
be safe.

Dose Too Low (135): Indication for Service (Reason) code


Applies to the presentation of an order to initiate or continue drug therapy at a dose or duration insufficient to be
effective.

Drug Interaction (145): Indication for Service (Reason) code


Applies to the presentation of a drug therapy with a drug interaction risk significant enough to render the therapy
unsafe.

Immunization Administered (331): Outcome of Service (Result) code


Applies to administration of or verification that the patient received the pharmacist-recommended immunization.

Increased Dose (345): Outcome of Service (Result) code


Applies to prescriber approval of a pharmacist recommendation to change a drug therapy that has a dose or
duration insufficient to be effective.

Initiated New Therapy (330): Outcome of Service (Result) code


Applies to prescriber approval of a drug therapy change following a pharmacist recommendation to initiate a drug
order due to an untreated indication for prescription therapy.

Initiated Cost Effective Drug (305): Outcome of Service (Result) code


Applies to prescriber approval of a more cost-effective drug following a pharmacist recommendation to change a
drug order due to a cost-efficacy issue.

Medication Reconciliation (202): Service Provided (Action) code


Applies to consulting a patient to reconcile his/her medications after being discharged from the hospital.

Medications Synchronized (332): Outcome of Service (Result) code


Applies to synchronizing fill dates for an appropriate patient and establishing a medication synchronization plan
with the patient.

Monitoring Checkpoint Complete (374): Outcome of Service (Result) code


Applies to completion of an Adherence Monitoring Checkpoint for a patient enrolled in the Adherence Monitoring
Program. Medication education was provided to the patient with an emphasis on the importance to adherence and
barriers to adherence were addressed, as appropriate.

MTM Center: A pharmacy, clinic, or other setting designated to provide MTM services using the Connect™
Platform and subject to OutcomesMTM’s approval.

MTM Pharmacist: A pharmacist designated by an MTM Center to provide MTM service using the Connect™
Platform and subject to OutcomesMTM’s approval.

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MTM Provider: An MTM Pharmacist and/or an MTM Center.

Needs Case Management (123): Indication for Service (Reason) code


Applies to the presentation of a patient who would benefit from case management. Applicable for select health
plans.

Needs Drug Therapy (120): Indication for Service (Reason) code


Applies to the presentation of a patient with an untreated indication for prescription therapy.

Needs Follow-up for Pregnancy Test (128): Indication for Service (Reason) code
Applies to the follow-up consultation with a female patient who previously sought a pregnancy test. Applicable for
select health plans.

Needs Lab Monitoring or Health Test (126): Indication for Service (Reason) code
Applies to the presentation of a patient in need of having a lab or screening. Applicable for select health plans.

Needs Immunization (121): Indication for Service (Reason) code


Applies to the presentation of a patient with an untreated indication for an immunization.

Needs Medication Assessment (124): Indication for Service (Reason) code


Applies to the presentation of a patient using a medication with a heightened risk of causing patient harm.

Needs Medication Reconciliation (102): Indication for Service (Reason) code


Applies to the presentation of a patient who has recently been discharged from the hospital and is an appropriate
candidate for having his/her medications reconciled.

Needs Medication Synchronization (122): Indication for Service (Reason) code


Applies to the presentation of a patient who is an appropriate candidate to synchronize his/her medication fill
dates.

Needs Patient Education (114): Indication for Service (Reason) code


Applies to the presentation of a patient with a need for additional education targeting the reason outlined in the
TIP overview.

Needs Pregnancy Test (127): Indication for Service (Reason) code


Applies to the presentation of a female patient who seeks a pregnancy test. Applicable for select health plans.

Needs Refill (163): Indication for Service (Reason) code


Applies to the presentation of a patient with a need for a medication refill targeting the medication outlined in the
TIP overview.

New or Changed Prescription Therapy (110): Indication for Service (Reason) code
Applies to the presentation of an order to initiate a new or changed prescription therapy.

New or Changed OTC Therapy (117): Indication for Service (Reason) code
Applies to the presentation of a patient with an untreated indication for over-the-counter therapy or for a patient
that is experiencing an adverse event, drug interaction, or is using an OTC therapy where there is no longer an
appropriate indication.

No Intervention Needed: Applies to TIPs generated by OutcomesMTM for which the proposed intervention is
obsolete (i.e., the drug therapy problem never existed, no longer exists or has already been resolved, so no action
is required by the pharmacist).

Patient Consultation (215): Service Provided (Action) Code


Applies to consulting a patient to address a drug therapy problem.

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Patient Education (214): Service Provided (Action) Code
Applies to educating a patient to address the information outlined in the TIP overview.

Patient Education and Monitoring (210): Service Provided (Action) Code


Applies to patient education and monitoring of a prescription or over-the-counter therapy. Minimum patient
education includes information related to the name of the drug, therapeutic class, directions for use, side effects,
warnings, storage requirements and missed dose actions as well as appropriate written material. Minimum patient
monitoring includes collecting information about patient satisfaction with therapy; symptom improvement, where
applicable; side effects; and adherence.

Patient Education Provided (314): Outcome of Service (Result) code


Applies to educating a patient about the information outlined in the TIP overview.

Patient Monitored & Enrolled (373): Outcome of Service (Result) code


Applies to the enrollment of a patient into the Adherence Monitoring Program where medication education was
provided to the patient with an emphasis on the importance to adherence and barriers to adherence have been
addressed, where appropriate. Claims with this result code mean the pharmacy is now accountable for the
patient’s adherence to the targeted medication throughout the remainder of the year. Applicable for select health
plans.

Patient Referred (323): Outcome of Service (Result) code


Applies to a patient who has been referred for case management. Applicable for select health plans.

Patient Refilled Rx (363): Outcome of Service (Result) code


Applies to completion of patient education for a needed medication refill when the patient confirmed he/she will
pick up the medication. Applicable for select health plans.

Patient Refused (380): Outcome of Service (Result) code


Applies to a patient’s refusal to participate in a Comprehensive Medication Review, to receive Patient Education
and Monitoring, to permit a physician consultation or to alter adherence behavior.

Prescriber: Any person legally authorized to prescribe pharmaceuticals for a patient.

Prescriber Consultation (205): Service Provided (Action) Code


Applies to consulting a prescriber to recommend a drug order change to resolve a cost-efficacy issue or drug
therapy problem.

Prescriber Refused Recommendation (375): Outcome of Service (Result) code


Applies to a prescriber’s refusal of a pharmacist’s recommendation to change a drug order to resolve a cost-
efficacy issue or a drug therapy problem.

Provided Pregnancy Test and Counseling (327): Outcome of Service (Result) code
Applies to completion of education and counseling for a female patient seeking a pregnancy test. Applicable for
select health plans.

Reason: The indication for service associated with an OutcomesMTM claim.

Result: The outcome of service associated with an OutcomesMTM claim.

Rx Validation: The presentation of pharmacist verified medication changes in the health plan’s prescription claim
records.

Severity Level: The highest reasonable and foreseeable healthcare benefit (or avoidance) the patient received as
a result of the pharmacist's intervention.

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Severity Level 1: Adherence Support
Automatically applies to all completed Comprehensive Medication Reviews and patient education services (with
the exception of New or Changed OTC Therapy). A pharmacist should select this severity level for all other
interventions that do not result in any other reasonable and foreseeable cost avoidance.

Severity Level 2: Reduced Medication Costs


Automatically applies to all successful Cost-Effective Alternative claims in combination with prescriber
consultations that result in changes in prescribed therapy. A pharmacist should select this severity level for all
other interventions that result in reasonable and foreseeable savings in drug product costs.

Severity Level 3: Prevented a Physician Visit


Applies to a drug therapy problem identified and resolved by the pharmacist for which it is reasonable and
foreseeable that the patient would have visited a physician if not addressed by the pharmacist.

Severity Level 4: Prevented an Additional Prescription Order


Applies to a drug therapy problem identified and resolved by the pharmacist for which it is reasonable and
foreseeable that the patient would have obtained a new prescription order if not addressed by the pharmacist.

Severity Level 5: Prevented an Emergency Room Visit


Applies to a drug therapy problem identified and resolved by the pharmacist for which it is reasonable and
foreseeable that the patient would have needed to visit the ER if not addressed by the pharmacist.

Severity Level 6: Prevented a Hospital Admission


Applies to a drug therapy problem identified and resolved by the pharmacist for which it is reasonable and
foreseeable that the patient would have been admitted to the hospital if not addressed by the pharmacist.

Severity Level 7: Prevented a Life-Threatening Situation


Applies to a drug therapy problem identified and resolved by the pharmacist for which it is reasonable and
foreseeable that the patient would have faced a life-threatening situation if not addressed by the pharmacist.

Suboptimal Drug (130): Indication for Service (Reason) code


Applies to the presentation of an order to initiate or discontinue drug therapy with suboptimal efficacy.

Telehealth: References CMRs performed through a HIPAA-compliant interactive audio and video
telecommunications system that permits real-time communication between a pharmacist and a patient while at
different sites.

Therapy Failure (320): Outcome of Service (Result) code


Applies to a monitoring situation whereby a pharmacist determined that a patient’s condition(s) was unresolved,
unstable or worsened as a result of drug therapy.

Therapy Success (310): Outcome of Service (Result) code


Applies to a monitoring situation whereby a pharmacist determined that a patient’s condition(s) was resolved or
stabilized as a result of drug therapy.

TIP: References the OutcomesMTM Targeted Intervention Program (TIP®). Identified through prescription claims
analysis, TIPs indicate possible drug therapy problems. TIPs are available in the MTM Opportunities queue in the
Connect™ Platform. Information provided within each TIP is for support purposes only and does not replace
clinical decision-making of a practicing pharmacist. All decisions relating to the provision, nature and/or extent of
services provided shall remain exclusively within the discretion of the practicing pharmacist. A pharmacist is r
equired to assess the validity and clinical appropriateness of a TIP prior to contacting the patient and/or
prescriber.

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Unable to Reach Prescriber After 3 Attempts (378): Outcome of Service (Result) code
Applies to a situation when an MTM Center has attempted to reach a prescriber at least three separate times, on
three different days without success.

Unable to Reach Patient After 3 Attempts (379): Outcome of Service (Result) code
Applies to a situation when an MTM Center has attempted to reach a patient at least three separate times, on
three different days without success.

Unnecessary Prescription Therapy (125): Indication for Service (Reason) code


Applies to the presentation of an order to initiate or continue a drug therapy that is not indicated.

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