Professional Documents
Culture Documents
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
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.
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.
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.
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.
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.
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.
• Each claim submitted via the Connect™ Platform is coded via a similar format.
o Indication for service (reason)
• 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.
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.
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.
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.
• 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.
• 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.
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
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)
PRESCRIBER CONSULTATIONS
The following billable services require a consultation with the prescriber and communication with the patient
regarding any changes in medications.
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
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
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
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
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
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
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
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
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
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
Documentation Requirements
Adherence – Underuse of Medication (160) 1. Date of initial adherence consultation
Patient Consultation (215)
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
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
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
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
Documentation Requirements
Adherence – Needs Monitoring (174) 1. Date the outcome was determined
Patient Consultation (215) 2. Prescription information
Monitoring Checkpoint Complete (374)
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
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
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?
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
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)
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
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
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.
• 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.
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.
• 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.
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 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.
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.
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.
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.
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).
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.
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.
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.
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.
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.