Pharmacare COB with Federal Plans

There are five different federal plans:

  • VO Veteran’s Affairs Canada
  • RC RCMP
  • CF Canadian Forces
  • IA Non-Insured Health Benefits
  • WC Worker's Compensation

In British Columbia, when a patient has federal coverage, prescriptions must be submitted to Pharmacare with a DE intervention code. This tells Pharmacare to adjudicate the claim as $0.00 and submit the total dollar value of the prescription to the federal plan. The DE intervention code is AUTOMATICALLY added to the Pharmacare claim.

Since all claims must be submitted to Pharmacare before adjudicating to another third party, the patient’s Pharmacare plan should be PC in the Patient folder. This allows the prescription to use the pricing rules for the patient’s federal plan (VO, RC, CF, IA or WC), but still adjudicate to Pharmacare.

Submitting claims to a federal plan with a DE intervention code

No additional steps are necessary if you want Pharmacare to adjudicate the claim as $0.00. Since the intervention code is added automatically, it does not have to be added manually before filling the prescription.

  1. Open the prescription in Rx Detail.
  2. The billing code in the Bill field should be PC followed by the federal plan and any other third parties that the patient subscribes to (eg. a Veteran’s Affairs patient could have the billing code PC/VO/CA).
  3. Continue to fill the prescription as usual.
  4. The PC claim will be rejected with E1 - Host Processing Error. Press the Skip TP action button.
  5. Adjudication will continue to the next third party in the prescription’s billing code; complete the prescription as usual.

To remove the DE intervention code, do the folllowing:

If you do not want Pharmacare to adjudicate the claim as $0.00 before submitting to the COB plan, the DE intervention code must be removed before the prescription is filled.

To submit claims to a federal plan, with primary payment occurring at PharmaCare:

  1. Open the prescription in Rx Detail.
  2. The billing code in the Bill field should be PC followed by the federal plan and any other third parties that the patient subscribes to (ex. PC/VO/CA).
  3. Press the Third Party tab. The PC claim should be displayed on the screen. This is Claim 1 for the prescription.
  4. In the Intervention Code section, highlight the DE row in the For Claim box.
  5. Press the Remove button. The DE intervention code is removed.
  6. Continue to fill the prescription as usual.

Cancelling a Pharmacare/Federal COB Prescription

When billing is reversed for a federal COB prescription, Pharmacare will reject the reversal, just as they rejected the original claim.

  1. Select Correct Rx Refuse from the Workbench or the Profile.
  2. The prescription opens in Rx Detail and the Third Party tab displays the PC claim. This is Claim 1 for the prescription. The Modify Reversal checkbox is selected.
  3. Press the Add button in the Intervention Code section.
  4. A row is added to the For Reversal box. Select RE from the Code dropdown list.
  5. Press the OK button. The reversal is submitted to the third parties.
  6. The PC reversal will be returned with Reversal Rejected and the response E1 - Host Processing Error. Press the Abort button.
  7. The reversal is successful and the prescription becomes Cancelled.