Did you know that MTM payments for certain TIPs may be broken into two different categories?
- MTM Intervention Payment = paid for the initial intervention and submission of a claim
- Rx Validation Payment = paid after the medication or therapy change displays in the health plan’s prescription claim records received by Outcomes
TIP and pharmacist-initiated claims may be eligible for validation payments if the result of the service provided by the pharmacist involves an initiated or discontinued therapy, changed medication, days supply, or dose, immunization administered, or medication refilled. Prescriber consultations, 90-day & 100-day fills and patient refill claims can all potentially earn an additional validation payment.
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 60 days following the MTM service date (encounter date). Of note: for Needs Refill TIPs, a refill must be processed within 7 days of the encounter date to validate.
Validation payments can range anywhere from $5 (i.e. patient refill) up to $120 (i.e. initiating statin therapy in persons with diabetes), depending on the nature of the intervention and what is required from the pharmacist’s recommendation. Validation payments may vary by health plan and are applicable for select plans.
Best practices to ensure claim validation:
- Process the claim via the patient’s prescription drug plan so it will be eligible for validation. Cash claims will not be seen in the claims data provided by the health plan.
- Ensure the encounter date reflects the date the result of the intervention was determined, which often aligns with the date the new or changed prescription is filled.
- If the patient is not yet due for the changed prescription to be filled, consider inactivating the prior prescription as a reminder to transition the patient to the new prescription at the time of next fill.
To see which MTM claims from your MTM center are eligible for validation, navigate to Service History > MTM Services and utilize the Validation Payment filter to see claims in the following categories:
- Validation in progress – MTM claim was approved, validation of the prescription fill in prescription claims data is pending
- Validation payment pending – MTM claim was approved and validating fill is present in prescription claims data (or lack of fill is validated for situations where therapy is discontinued)
- Validation paid – validation payment has been paid to MTM center
- Validation rejected – no validating fill was identified during 60-day window
TIPs that may include an additional validation payment include:
- Adherence - Needs 90-day Fill
- Adherence - Needs 100-day Fill
- Adherence - Needs 100-day or 90-day Fill
- Adherence- Needs Check-in + 90-day Fill
- Adherence- Needs Check-in + 100-day Fill
- Cost-effective Alternative
- Drug Interaction
- High Risk Medication
- Needs Drug Therapy
- Needs Immunization
- Needs Final Fill
- Needs Refill
- Suboptimal Drug Selection