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The three top questions asked by pharmacists

If your question does not appear on this list, consult our FAQ.

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Did you know that the TELUS Health drug claims service is already used by 97% of pharmacies in Canada?

The TELUS Health drug claims service manages the payment of point-of-sale claim settlements. Use it to send and receive claim settlements and take advantage of numerous benefits:

  • Determination of product eligibility for most requests

  • Transaction conciliation

  • Instant access to our database for employees and their dependents

  • Instant confirmation of coverage

  • Automated payment of each transaction from the bank account of your choice

  • Complimentary access to our Pharmacy Support Centre where your questions and problems will be resolved

Our electronic claim settlement exchange service is offered to all pharmacies in Canada. We manage settlement claims on behalf of 15 Canadian insurers and payers and transmit more than 250 million drug claim settlements every year under our service offer.

 

FAQ on settlement claims

We have compiled the list of most frequently asked questions. If you do not find what you are looking for, please contact us below.

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TELUS Health assigns a provider number to any pharmacy that wishes to submit electronic transactions for payment. Before an establishment is recognized, several factors are taken into consideration. A pharmacy seeking a provider number must satisfy the following criteria:

  • The pharmacy must be an authorized establishment recognized by the appropriate regulatory agency.
  • The pharmacy must also be owned and operated by a certified pharmacist and under regular circumstances.
  • If a physician holds a financial interest in a pharmacy, the physician and all his or her medical employees are prohibited from participating in the pharmacy’s management and/or operation activities.
  • If a registered pharmacy would like its compensation claims to be submitted to TELUS Health via an external certified distribution point (including external distribution centres, automated drug systems and distribution counters), it must request a supplier number for this distribution point. After verifying that the distribution point complies with all the requirements for a supplier number, TELUS Health will issue a unique supplier number for that distribution point. A registered pharmacy is prohibited from using its own supplier number to submit compensation claims via an external distribution point.

Under exceptional circumstances it may be relevant to assign a supplier number to a physician who also dispenses prescription medications if no pharmacy is registered in our user directory within a radius of 30 km from the medical clinic in question. The physician must provide proof of status as a licensed physician authorized to dispense medication. Please contact our Support Centre for more details.

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Cardholders have told us that some pharmacists do not explain the reasons for settlement claim refusal when this occurs. Patients have complained that pharmacists are content with the blanket statement that the card has been refused! Here are some of the reasons why a card may be refused:

  • Unregistered dependent (newborn, new spouse, etc.)
  • Erroneous dependent code
  • The dependent has surpassed the age of eligibility
  • Incorrect date of birth

The TELUS Health Pharmacy Manual (pdf format) presents the types of messages your software may display (section 4). If you receive one of these messages, please convey the information to the patient. If it is a coverage problem, please ask the patient to notify the plan sponsor’s claims office to register the new dependent. Verify that the date of birth is accurate or that the appropriate details for a full-time student is provided. Once the revised information has been sent to the insurance company, the TELUS Health files will be electronically updated. Please note that the refusal messages will continue to be displayed until the plan sponsor notifies the insurer.

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The Pharmacy Support Centre is intended only for pharmacists and dentists.

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The average call lasts approximately three minutes; many are shorter.

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The Pharmacy Support Centre receives more than 900 calls on weekdays, and more than 500 on weekends.

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No. All amendment requests must originate from the insurer.

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It is very important. TELUS Health uses it for identification purposes along with the relationship code. If the date of birth or relationship code entered by the pharmacist does not match those appearing in our records, the claim is rejected. The same applies if the relationship code entered by the pharmacist does not match our records.

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TELUS Health uses the date of birth as the primary identification element. It is therefore important for the pharmacist to enter the correct date of birth to verify the identity of the person using the Assure™ card. If the Support Centre were to provide this information, it would compromise the integrity of the identification process.

TELUS Health staff cannot confirm that the date of birth entered in your records matches the information provided by the insurer. If the patient confirms that the date of birth you indicate is correct but is different from the patient information we have on file, the patient must contact his or her employer to resolve the issue. The insurer will notify TELUS Health of the change shortly after receiving the amendment requested by the employee. If this occurs and the patient is unable to wait for the amendment to be made (the process can take several days), he or she must pay cash and present the receipt to TELUS Health for direct reimbursement.

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In the EDI assessment process, entering the correct relationship code for the patient to whom medications are dispensed is as important as entering the date of birth in its correct format. Use of the relationship code allows us to validate settlement claims and manage the review of the use of medications as well as individual limits such as deductibles, maximums, co-pay, etc. TELUS Health uses the following relationship codes and descriptions:

  1. Primary holder – usually the employee of the policyholder. This person’s name almost always appears on the card.
  2. Spouse of the primary cardholder. In some cases, the name of the spouse will appear on the card alone or with that of the primary cardholder. A separate card can be issued in the spouse’s name if, for example, the spouse does not have the same surname.
  3. Dependent of the primary cardholder – generally a minor under age 18 or 19 , but who may be 20 or older, depending on the terms of the group insurance plan.
  4. Non-taxable dependent child of the primary cardholder – a child who remains eligible as a full-time student. In some cases, a separate card is issued in the child’s name and bears the embossed marking “OA” and an expiration date, generally corresponding to the end of the school year.
  5. Non-taxable dependent child of the primary cardholder – the child remains eligible due to a physical or mental disability. In some cases, a separate card is issued in the name of the guardian of the disabled dependent and bears the embossed marking “DD”.

Using the appropriate relationship code but the incorrect date of birth will result in the refusal of the settlement claim. The same applies for a correct date of birth but incorrect relationship code. It is imperative that both the date of birth and relationship code match the information in our system for payment purposes.

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One standard element of the Assure™ card is the drug use review. This additional information can improve your customer service experience by verifying potential problems your pharmacy’s software may not cover.

For the program to be effective, we must receive accurate information about the quantity required. Most of our plans are limited to a 34-day supply for immediate-release drugs, and 100 days for maintenance drugs. (Please consult the Pharmacy manual (pdf format) for drug classification information.) The correct use of the quantity field is essential to ensure the fair payment of settlement claims and accurate messages from the drug use review.

Comment: For “PRN” (as needed) and “Take as directed” medications, it may be difficult to determine the appropriate quantity. In this case, a realistic estimate is sufficient.

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The most difficult pharmaceutical product to manage in real time is a medication that is prepared extemporaneously or compounded. Although fewer than 1.2% of the electronic settlement claims we receive are for compounds, these represent 15% of the time our internal auditors spend determining their eligibility. We are aware that pharmacists are put off when the settlement claim is submitted to us only to find out much later that the preparation did not satisfy the audit criteria.

We reimburse compound preparations only if the primary active ingredient is normally covered by the patient’s drug insurance plan and it is not simply a duplicate of a commercial product. To avoid a claim request being refused in the days or weeks after the drug is dispensed, you can call our Pharmacy Support Centre to determine whether the product is eligible under the plan. If none of the ingredients in a compound preparation requires a prescription, you can verify whether it is covered by contacting the Pharmacy Support Centre. This will help you to avoid unexpected refusals.

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Whenever possible, we ask pharmacists to include the DIN for the primary prescription drugs (if applicable) used in the preparation with their settlement claims for compound preparations. This allows us to conduct an online verification of the claim’s eligibility. For example, let’s consider a settlement claim for a compound preparation composed of equal parts 1% hydrocortisone cream and 2% ketoconazole cream. The claim must include the DIN code for the ketoconazole cream and the appropriate compound preparation code. The ketoconazole cream is an eligible prescription drug under most drug insurance plans. However hydrocortisone 1% cream is purchased over the counter and as such, its purchase is not reimbursed by most plans. If a compound preparation does not contain a prescription drug, include the DIN code of one of the ingredients with the claim. If you are required to use a general PIN for compound preparations (examples: 00999999 or 00900710) when submitting a settlement claim, we strongly recommend contacting the Pharmacy Support Centre to confirm the claim’s eligibility. Consult our most recent pseudo-DIN list.

When submitting the DIN for compounded preparations, please be aware that at least one ingredient must be considered eligible. Preparations containing Aquaphor (Eucerin), glycerine and water are not eligible under any of our plans. If you are unsure about the eligibility of compound preparations, please contact the Pharmacy Support Centre for assistance.

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TELUS Health evaluates settlement claims according to standard professional pharmacy fees. These fees are set by provincial laws, negotiations with provincial pharmacy organizations or individual pharmacies, as is the case in Ontario.

Once an amount is declared and coded in our evaluation system, we take complete control of processing the standard pharmacy fees. Where permitted by law, in our view, suppliers who are interested can claim fees as long as they charge cash-paying customers and third-party payers the same amount. In some provinces, such as Ontario, this amount must be declared to a professional regulatory agency and displayed in public view on the premises.

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For us to be able to process the transaction fee portion that is submitted to reflect the standard fee, please notify us of any changes. Please complete the Pharmacist Profile Amendment Form and indicate the new standard fee along with its effective date, and send the form by fax to 1 866 840-1466.

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We often hear pharmacy customers tell us that they were required to pay out-of-pocket to compensate for ingredient price cuts. Our price lists are set based on numerous reliable sources and allow for a reasonable mark-up. In Quebec, rates are established in keeping with our contract with the AQPP. Under the terms of a section of the contract to which we are bound, you agree to cover the cost of the ingredients we determined, and not pass these additional costs on to your clients.

If you paid more for a drug than the amount allocated in the settlement, please contact the TELUS Health Support Centre. We will ask you to fax us a copy of a recent invoice indicating the ticket number assigned to your claim and will make the necessary adjustments. The only restrictions are that the difference between the settlement claim you submit and the purchase invoice amount must be over $2, and we must receive the invoice within seven days following the purchase of the medication.

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Most drug insurance plans require participants to make some kind of financial contribution (deductible, share, co-assurance), under the terms of which the insured must cover a portion of the drug purchase price. Some plans may impose a ceiling amount on professional fees or a deductible amount that is equivalent to these fees, which limits the amount paid out by the insurance company to cover your professional fees. Other plans only reimburse the equivalent of generic drug prices or the purchase of drugs appearing on an Integrated Care type form. However the customer can ask to receive the product as prescribed. You may charge the customer a cash amount equivalent to his or her share, any difference between your standard professional fees and the authorized maximum, and the price difference between the prescribed product, if applicable, and the dispensed product. If you have any questions about ingredient costs, please contact the Pharmacy Support Centre and ask for a call-back from a pharmacist. He or she will be pleased to answer your questions and work with you through any problems that arise from our operations.

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Plans that offer direct EDI payment for drugs are beneficial for employees, which is good for the pharmacy and its customers. The reality of only having to charge customers the regular price is imperative to its success. This includes charges for oral contraceptives and diabetic supplies that often apply reduced dispensing fees. Accordingly, there’s no need to charge TELUS Health clients for EDI services that customers who pay cash, or other customers with direct payment plans do not pay for. In fact, the contract binding you with TELUS Health includes this requirement.

This means that if you forge special ties with other direct payment networks, you must commit to the same fees for TELUS Health Assure™ cardholders. We follow the same rules as your competitors. Our affiliated insurers must benefit from the same cost prices as those you charge our competitors. (Note: This does not prevent you from signing preferred supplier agreements with employers or individual groups in the industry.)

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There are many reasons for a lower payment. It is possible that the price linked to the DIN is reduced if the pharmacist submits a price that exceeds the amount TELUS Health pays according to information on file. The dispensing fees may be lower if the pharmacist submits fees that exceed the amount generally paid by TELUS Health, or the group plan imposes a ceiling in this respect. Differences can also occur if the drug insurance plan implements a policy on generic substitution, cost determination based on the reference product, or for cost determination based on a maximum eligible amount. Moreover, reductions can occur if the drug supply exceeds 34 days for acute use drugs, or 100 days for maintenance use drugs.

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When the Assure™ card is presented to the pharmacist, always ask if the name appearing on the card is the name of the policyholder. Under some plans, each family member has an individual card bearing their name in embossed letters. It never hurts to ask!

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TELUS Health manages the drug insurance plans for several Canadian life insurance companies. These companies have entrusted us with dealing with pharmacies and other electronic suppliers on their behalf to facilitate the rollout of their direct benefits payment programs. Insurers appreciate this and are intent on maintaining their ties with plan sponsors (employers) and their employees and have asked us not to directly intervene with either party. We strictly uphold this rule.

We are aware that this sometimes results in the pharmacist being approached by a dissatisfied client. Sometimes, this is inevitable. Our Pharmacy Support Centre strives to provide you with all the possible information to help your customer, but this is sometimes not enough to resolve the issue.

In this case, simply ask your customer to contact his or her employer plan administrator for answers from the insurer. If the matter results in the non-payment of a settlement claim, your best option is to charge cash. Once the problem is resolved, the card holder can mail the receipt to the insurer for a refund.

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