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Revised January, 2010 CONFIDENTIAL AND PROPRIETARY - page 2 / 31

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CONFIDENTIAL AND PROPRIETARY

Table of Contents

Walgreens Health Initiatives’ Overview ........................................................................... 4 Member Eligibility ............................................................................................................ 4 Identification Card ........................................................................................................... 4 Figure 1. Walgreens Health Initiatives’ Identification Card........................................... 5 Formulary Changes ..................................................................................................... 5 General Walgreens Health Initiatives Policies................................................................. 6 Access to and Retention of Records............................................................................ 6 Compliance with Laws and Regulations ...................................................................... 6 Signature Logs............................................................................................................. 6 Confidentiality Requirements....................................................................................... 6 Liability Coverage ........................................................................................................ 7 Prescription Medication Fraud, Waste, and Abuse...................................................... 7 How to Report Potential Fraud, Abuse, or Suspicious Activity ................................. 7 Provider Relations Department ....................................................................................... 8 Network Participation................................................................................................... 8 Medicare Part D Participation ...................................................................................... 8 Contracts and Amendments ........................................................................................ 9 Pharmacy Demographic Database.............................................................................. 9 Address Changes..................................................................................................... 9 PSAO/TPA Affiliations Guidelines................................................................................ 9 Billing and Reimbursement ........................................................................................... 10 Prescription Claims Submission Guidelines .............................................................. 10 POS System .............................................................................................................. 10 Billing Compounds..................................................................................................... 11 Clinical Overrides on Claim Rejections...................................................................... 12 Payor Sheet............................................................................................................... 13 NCPDP Standard Universal Claim Form (UCF)......................................................... 13 Sample of Universal Claim Form Below................................................................. 14 Rx Origin Code.............................................................................................................. 16 CMS Non-Matched NDC List ........................................................................................ 16 Processing of Prescription Paper Claim Forms............................................................. 16 Payment Cycles ............................................................................................................ 16 Checks .......................................................................................................................... 17 EFT (Electronic Funds Transfer) ................................................................................... 17 Remittance Advices....................................................................................................... 17 835 Remittance Files..................................................................................................... 17 Personal Health Information (PHI) Data Transmission Policy.................................... 17 Pricing ........................................................................................................................... 18 Medication Classification............................................................................................... 18 Questions Regarding Claims Submission or Status...................................................... 18 Walgreens Health Initiatives’ MAC Pricing Appeal Process .......................................... 19 Criteria for MAC Appeal............................................................................................. 19 Documentation required for MAC Appeal .................................................................. 19 Long-Term Care............................................................................................................ 19

Walgreens Health Initiatives – Pharmacy Manual

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