Pharmacy

Sector Services
Claims, Provider Payments & Entitlements

Quick Questions

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> Detailed Questions
> Forms
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What is Pharmacy claiming?
Pharmacy claims cover the medicine subsidy and dispensing costs associated with supplying prescribed pharmaceutical items to patients.

Pharmaceuticals can be dispensed to a patient as a single dispensing or in partial dispensing. A partial dispensing can be provided to patients in weekly, fortnightly or monthly lots. The first dispensing lot is called an Initial Dispensing and all subsequent lots (for the same prescription item) are referred to as Repeats.

The Services are defined in the Agreement. Pharmacy payments are determined by the Agreement and variations to the Agreement.

Different transaction types generally have different processing requirements, for example:

Supply orders and Controlled Drug items have no patient contribution (known as abatement)
Nicotine Replacement Therapy (NRT) items are processed without patient details
The patient contribution for Special Food items are calculated differently when different flavours are claimed on the same prescription form
Owe and Wastage items have no abatement or dispensing fees.

PHARMAC supplies a monthly Pharmaceutical Schedule, containing pharmaceutical pricing and dispensing regulations, which are used to determine the subsidies.

Dispensing costs are defined in the Agreement, and are funded by the DHB.

A Pharmacy claim can be submitted electronically or on paper. The claim may contain multiple prescription items that may comprise one or more pharmaceuticals. Pharmaceuticals with two or more components are known as mixtures.

Pharmacies have the ability to submit corrected individual items to Sector Services that have been previously claimed incorrectly. This correction involves submitting credits and resubmits at the prescription item level. The prescription number is used to identify the transactions concerned.

Pharmacy claim items may be submitted with a Special Authority number. The Special Authority number is used to determine the amount of the subsidy to be paid. A Special Authority number is also a mandatory field when restricted pharmaceuticals are claimed.

During claim processing, the Special Authority number is checked to confirm that it matches a Special Authority number issued for the patient, and that the Special Authority covers the pharmaceutical being claimed.

Who do I contact to order more Pharmacy stationery?
The following stationery items can be obtained from Wickliffe Limited:

Pharmaceutical (Prescription) Subsidy Cards
High Use Health Card applications
Bulk Supply Order forms
Wholesale Supply Order forms
Practitioner’s Supply Order forms

The contact details for Wickliffe are 0800 259 138. Please note that Wickliffe Ltd will request your claimant details.

Reference: Sector Services procedure to support the Pharmacy Services Agreement.

Who do I contact to obtain more Electronic Batch Record forms?
Sector Services print and distribute these forms. Please telephone Sector Services’s Contact Centre on 0800 353 2425.
Reference: Sector Services procedure to support the Pharmacy Services Agreement.

Alternatively an electronic copy is available from the forms section of the Sector Services website:

Please link the publication (from the FAQ’s attachments doc link) called:
Batch Record Form page 1
Batch Record Form page 2

What are Pharmacy Agreements?
Sector Services currently creates agreements on the Funders behalf. Once the draft Agreement is completed copies are distributed for all parties to sign and, once signed, the contract is activated and the claims processing systems are able to accept claims under this contract.

Agreements are generally established for a fixed term and are renewed periodically.

If you have any questions or wish to arrange an agreement then please contact your District Health Board (DHB) in the first instance.

Who do I contact if I want information regarding my contract and/or agreement?
Contact our Dunedin Team:
Level 4
229 Moray Place
Private Bag 1942
Dunedin
Ph: 0800 281 222 Option 4
Fax: 03 474 8582

Where should I send my claims?
Send all completed claims to:

Pharmacy Claims
Sector Services
179 St Hill Street
Private Bag 3015
Wanganui 4500

How do I contact Sector Services?
For further information, please call the Sector Services Contact Centre on:
0800 353 2425 or 06 349 1990 or Facsimile 06 349 1983
Monday – Friday 8:00am – 5:00pm,
Except Wednesday when the Contact Centre’s hours are 9:30am – 5:00pm

Are there any restrictions on how we dispense a Dentist prescription?
The maximum quantity for a community pharmaceutical that will be subsidised for a dental prescription is only such quantity as is necessary to provide treatment for a period not exceeding five days and where the prescription specifies a repeat, one further period not exceeding five days.
A dental prescription cannot be dispensed all at once (stat).

There is an exception for Sodium Fluoride. A dentist may prescribe for an extended treatment period up to three months.

Reference: Pharmaceutical Schedule Section A, Clause 3.3

I have sent in my Pharmacy claim via disk. When do I receive my reports?
Error and Variance Reports: These are sent as soon as your claim is processed.

Buyer Created Tax invoice:This will be sent to you five days prior to the relevant payment date.

Reference: Sector Services procedure to support the Pharmacy Services Agreement.

My Pharmacy claims electronically. What do we do with the hard copy prescriptions?
Pharmacies must retain prescription batches for five months. After the five month period, prescription batches must be submitted to Sector Services once or twice each month.

Reference: Pharmacy Procedures Manual Clause 3

Detailed Questions

I have dispensed the first dispensing of a three-month prescription. At the date of dispensing the product was a funded item in the Pharmaceutical Schedule. I have now been advised that this product is no longer funded. Will Sector Services pay for the repeat dispensings?
No. Sector Services reimburses pharmaceuticals according to the subsidies listed in the Pharmaceutical Schedule at the time of dispensing.

Reference: Pharmacy Services Agreement: Clause H1.2

How do I know if PHARMAC is no longer funding a pharmaceutical?
PHARMAC distribute monthly Pharmaceutical Schedule updates which contain:

new listings
changes to restrictions
delisted items

Unless otherwise stated, these updates are effective from the 1st of the month.

Medicines that are no longer funded are listed on the delisted medicines list.

Reference: Pharmaceutical Schedule

The Pharmaceutical Schedule contains prescribing and dispensing restrictions. Where do I find the definition of each restriction?
The definitions of these restrictions are detailed in the Pharmaceutical Schedule under the General Rules section.
Reference: Pharmaceutical Schedule Section A, Part I

We have received a prescription for Oxybutynin Oral Liquid. The Doctor has only prescribed 100 mls. Oxybutynin Oral Liquid comes in 437ml Original Pack. We will be breaking the Original Pack to dispense the 100 mls. Are we able to claim for the remaining 337mls that we have to discard?
The Pharmaceutical Schedule outlines the reimbursement rules for Original Pack’s.
Only claim what has been dispensed (100 mls) however, because this pharmaceutical is subsidised as original packs, 437 mls will be reimbursed.

Reference: Pharmaceutical Schedule Section A, Part III, Clause 3.4

What is the maximum quantity that will be subsidised for selected pharmaceuticals on a Practitioner Supply Order?
The Pharmaceutical Schedule lists the community pharmaceuticals that are subsidised on a Practitioner Supply Order and the maximum quantity that will be subsidised.

More details for Practitioner Supply Order restrictions are listed in the Pharmaceutical Schedule (Section A: General Rules, Part IV Miscellaneous Provisions, Clause 4.2).

Reference: Pharmaceutical Schedule Section E, Part I

Can a Prescriber have a product on a Practitioner Supply Order that has a restriction of “Special Authority for Subsidy”?
No. A “Special Authority” is an application process in which a Prescriber requests government subsidy on a community pharmaceutical for a named person.
Reference: Pharmaceutical Schedule

I thought I submitted my claim to Sector Services within the correct time frames. I have now received a fax from Sector Services informing me that my claim has not been received on time. Can you please explain what this fax means?
Pharmacy claims must be received within the first four business days following the claim period to be paid on the payment date. For example, if the claim period ended on Monday the 15th, Sector Services must have received your disk by Friday the 19th (due date). If Sector Services has not received your Pharmacy disk by the end of the fourth business day following the claim period, your Pharmacy will be sent a fax to advise that the claim has not been received.

Reference:. Pharmacy Services Agreement Part H, Clause H3.2

I have submitted my claim to Sector Services on a disk. I have now received a fax from Sector Services stating they are unable to retrieve the file on the disk. What do I do?
If Sector Services are unable to retrieve the file from the disk then Sector Services will require a replacement disk. Please make up a further claim and forward to Sector Services.
Reference: Sector Services procedure to support the Pharmacy Services Agreement.

Forms
Please link the publication (from the FAQ’s attachments doc link) called:
Batch Record Form page 1
Batch Record Form page 2

Pharmaceutical Review Services Claim Form
http://www.psnz.org.nz/public/cop/cpc/Forms/claim%20form.DOC

Publications

Claiming Specifications
Pharmacy Data Specifications v3.00.02 August 2006 (PDF, 300 KB)
Pharmaceutical Cancer Treatments PCT Electronic Claims Data Specifications v1.4 May 2006 (PDF, 411 KB)

Claiming Guidelines
Error Codes for Community and PCT Pharmacy Electronic Claiming (PEC) V6.1 Booklet (PDF, 228 KB)
Pharmacy Procedures Manual: Version 3.1, Final 08 September 2008 (PDF, 184 KB)

NB: If you have any questions with regard to the Pharmacy Procedures Manual please contact your District Health Board (DHB) in the first instance.

Contact Centre News and Views
A quarterly newsletter sent out to providers, DHB's and Health professionals by the Contact Centre and includes articles, FAQ's, reminders and updates.

Links
Care plus
www.moh.govt.nz/moh.nsf/indexmh/phcs-funding-careplus
www.moh.govt.nz/moh.nsf/indexmh/phcs-projects-careplusservice

Community Service Cards
www.moh.govt.nz/moh.nsf/indexmh/phcs-funding-csc

District Health Boards New Zealand
www.dhbnz.org.nz

High Use Health Cards
www.moh.govt.nz/moh.nsf/indexmh/phcs-funding-huhc

High Use Health Cards
Claims, Provider Payments & Entitlements, High Use Health Cards

Medicines Control
www.moh.govt.nz/moh.nsf/indexmh/medicinescontrol

Medicines Regulations
www.legislation.govt.nz/regulation/public/1984/0143/latest/DLM95668.html

Medsafe
www.medsafe.govt.nz

MIMS – New Ethicals
www.mims.co.nz/mims_ne/mimsne_index.html

National Drug Policy
www.ndp.govt.nz

National Health Index
Claims, Provider Payments & Entitlements, National Health Index

National Pharmacy Services Framework:
www.dhbnz.org.nz/Site/SIG/NPSF/Default.aspxx

New Zealand Legislation
www.legislation.govt.nz

Nicotine Replacement Therapy
Claims, Provider Payments & Entitlements, Nicotine Replacement Therapy

PHARMAC
www.pharmac.govt.nz

PHARMAC Pharmaceutical Schedule
www.pharmac.govt.nz/schedule.asp

Pharmaceutical Co-Payments
www.moh.govt.nz/moh.nsf/indexmh/phcs-funding-pharmaceutical

Pharmaceutical Society of New Zealand
www.psnz.org.nz

Pharmaceutical Subsidy Cards
www.moh.govt.nz/moh.nsf/indexmh/phcs-funding-psc

Pharmacy Council of New Zealand
www.pharmacycouncil.org.nz

Pharmacy Guild of New Zealand
www.pgnz.org.nz

Pharmacy licences
www.moh.govt.nz/moh.nsf/indexmh/medicinescontrol-pharmacylicences

Pharmacy Practice Handbook
www.psnz.org.nz/public/evolve/notice.aspx?NoticeID=65

Special Authority
Claims, Provider Payments & Entitlements, Special Authority

Special Authority – Electronic
Claims, Provider Payments & Entitlements, Special Authority – Electronic (ESA)

SuperGold Cards
www.supergold.govt.nz

Please note: you should not rely solely on the answers provided here; the contracts applicable to each provider and all relevant legislation must be consulted to determine the full rights & liabilities applicable to any service provider or funder.

Page last updated: 10 March 2009