Required when Basis of Cost Determination (432-DN) is submitted on billing. Durable Medical Equipment (DME), these must be billed as a medical benefit on a professional claim. A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Required if identification of the Other Payer Date is necessary for claim/encounter adjudication. *Note: Code 09 is a negative amount and is not a valid option for field 351-NP. Member Contact Center1-800-221-3943/State Relay: 711. Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. Pharmacy Billing Procedures and Forms section of the Department's website, NCPDP Uu~Daw 0 Cannot Be Submitted Ms Drug W/Avail Generics~50740~Error List Daw0 Cant Be Submit Ms Drug W/Avail Gen. Prescriber has indicated the brand name drug is medically necessary. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a non-preferred formulary product. This field is required when the plan is a participant in a Medicare Part D program that requires reporting of benefit stage specific financial amounts. PB 18-08 340B Claim Submission Requirements and Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current. Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). Express Scripts 0 1 = Proof of eligibility unknown or unavailable. All services to women in the maternity cycle. Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Generic Drug Not in Stock, NCPDP EC 22-M/I DISPENSE AS WRITTEN CODE~50021~ERROR LIST M/I DISPENSE AS WRITTEN CODE and return the supplemental message Submitted DAW code not supported. Medication Requiring PAR - Update to Over-the-counter products. Colorado Pharmacy supports up to 25 ingredients. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Prescriptions generally cannot be dispensed in quantities less than the physician ordered unless the quantity ordered is more than a 100-day supply for maintenance medications or more than a 30-day supply for non-maintenance medications. WebIts content included administrative items and other artifacts for Centers for Medicare & Medicaid Services (CMS) Quality Reporting Programs, State all-payer claims databases (APCDs), Children's Electronic Health Record (EHR) Format, and Agency for Healthcare Research and Quality (AHRQ) Patient Safety Common Formats, as well as standards for AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION. WebThese CPT codes are not used under Medicare Part B, but may be used by Medicaid, private health insurers, or Medicare Part D plan administrators in determining reimbursement for MTM services. Delayed notification to the pharmacy of eligibility. All pharmacy PARs must be telephoned, faxed, or submitted via Real Time Prior Authorization via EHR, by the prescribing physician or physician's agent to the Pharmacy Benefit Manager Support Center. Note: the pharmacy may call the Pharmacy Support Center to request a zero co-pay if the medication is related to the treatment or prevention of COVID-19, or the treatment of a condition that may seriously complicate the treatment of COVID-19. Local and out-of-state pharmacies may provide mail-order prescriptions for Medicaid members if they are enrolled with the Health First Colorado program and are registered and in good standing with the State Board of Pharmacy. Substitution Allowed - Pharmacist Selected Product Dispensed, NCPDP 22-M/I DISPENSE AS WRITTEN CODE~50021~ERROR LIST M/I DISPENSE AS WRITTEN CODE and return the supplemental message Submitted DAW code not supported. : Illustration of Cost Reimbursable Basis of Payment Types and their Components 4.1.3.1 COST REIMBURSABLE WITH NO FEE Definition This basis of payment provides only for the reimbursement to the contractor of actual costs incurred.. Pharmacies are expected to keep records indicating when member counseling was not or could not be provided. COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT, 03 = Bank Information Number (BIN) Card Issuer ID. Required when Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. Reimbursement Rates for 2021 Procedure Codes Required if Other Payer Amount Paid Qualifier (342-HC) is used. Required for the partial fill or the completion fill of a prescription. Effective November 1, 2022, the Department is implementing a list of family planning-related drugs that may be covered pursuant to existing utilization management policies as outlined in the Appendix P, PDL or Appendix Y, if applicable. The maternity cycle is the time period during the pregnancy and 365days' post-partum. Required when additional text is needed for clarification or detail. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Unless otherwise communicated in the PDL or Appendix P, maintenance medications may be filled for up to a 100-day supply, and non-maintenance medications may be filled for up to a 30-day supply. WebAWP Reimbursement Basis - Complete the following tables using the drug reimbursement that your organization is willing to guarantee on a dollar-for-dollar basis for each year of the contract. If a member requires a refill before 50% of the day supply has lapsed, please provide the Pharmacy Support Center details of the extenuating circumstances. Reimbursement Applicable co-pay is automatically deducted from the provider's payment during claims processing. Pharmacies must complete third-party information on the PCF and submit documentation from the third-party payer of payment or lack of payment. Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) Required when Basis of Cost Determination (432-DN) is submitted on billing. Exception for DEA Schedule II medications:Initial Incremental fills are allowed for DEA Schedule II prescription drugs dispensed to ALL members. Required if this value is used to arrive at the final reimbursement. If the medication is not on the family planning-related drug list, then the prescriber will need to complete a prior authorization to confirm that the drug was prescribed in relation to a family planning visit. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a cost share differential due to the selection of one pharmacy over another. Required when utilization conflict is detected. Web8-5-4: BASIS FOR REIMBURSEMENT DETERMINATION: Reimbursement amount = actual construction cost x (total service area (acres) - total development area (acres)) total service area (acres) A. For DEA Schedule 2 through 5 drugs, 85 percent of the days' supply of the last fill must lapse before a drug can be filled again. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. Download Standards Membership in NCPDP is required for access to standards. Required if Previous Date Of Fill (530-FU) is used. Required when Other Payer ID (340-7C) is used. WebIn a physical inventory model, a prescription for an Eligible Patient could be filled partially with drugs from the Section 340B inventory and partially with drugs from the non-Section 340B inventory for such reasons as inventory shortage, short Required when a product preference exists that needs to be communicated to the receiver via an ID. Drugs produced by companies that have signed a rebate agreement (participating companies) are generally a Health First Colorado program benefit but may be subject to restrictions. Required if a repeating field is in error, to identify repeating field occurrence. For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. Pharmacy RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Billing Guidance for Pharmacists Professional and Required for 340B Claims. The Department does not pay for early refills when needed for a vacation supply. When a pharmacy has exhausted all authorized rebilling procedures and has not been paid for a claim, the pharmacy may submit a Request for Reconsideration to the pharmacy benefit manager. RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET Web419-DJ Prescription Origin Code =Not specified 1=Written 2=Telephone 3=Electronic 4=Facsimile NA Not used by DEEOIC 420-DK Submission Clarification Code =Not specified, default 1=No override 2=Other override 3=Vacation Supply 4=Lost Prescription 5=Therapy Change 6=Starter Dose 7=Medically Necessary 8=Process compound for Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required.". Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Required - If claim is for a compound prescription, list total # of units for claim. Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim. Imp Guide: Required, if known, when patient has Medicaid coverage. Required when the Other Payer Reject Code (472-6E) is used. 01 = Amount applied to periodic deductible (517-FH) Payer Specifications D.0 This dollar amount will be provided, if known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount. 522-fm basis of reimbursement determination r 523-fn amount attributed to sales tax r 512-fc accumulated deductible amount r 513-fd remaining deductible amount r 514-fe remaining benefit amount r 517-fh amount applied to periodic deductible r 518-fi amount of copay r 52-fk amount exceeding periodic PB 18-08 340B Claim Submission Requirements and Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. These source documents, in addition to any work papers and records used to create electronic media claims, shall be retained by the provider for seven years and shall be made readily available and produced upon request of the Secretary of the Department of Health and Human Services, the Department, and the Medicaid Fraud Control Unit and their authorized agents. Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. 03 =Amount Attributed to Sales Tax (523-FN) Federal regulation requires that drug manufacturers sign a national rebate agreement with the Centers for Medicare and Medicaid Services (CMS) to participate in the state Medical Assistance Program. The form is one-sided and requires an authorized signature. Web8-5-4: BASIS FOR REIMBURSEMENT DETERMINATION: Reimbursement amount = actual construction cost x (total service area (acres) - total development area (acres)) total service area (acres) A. Required when Help Desk Phone Number (550-8F) is used. Pharmacies may call the Pharmacy Support Center to request a quantity limit override if the medication is related to the treatment or prevention of COVID-19, or the treatment of a condition that may seriously complicate the treatment of COVID-19. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Required if Other Payer Amount Paid (431-Dv) is used. %%EOF Required to identify the actual group that was used when multiple group coverage exist. ), SMAC, WAC, or AAC. Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. 639 0 obj <> endobj In addition, some products are excluded from coverage and are listed in the Restricted Products section. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). Sent when Other Health Insurance (OHI) is encountered during claims processing. A pharmacy should utilize field 461-EU on a pharmacy claim to indicate 6-Family Plan to receive a $0 co-pay on family planning related medications. 1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads.
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