All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. 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 not used) for this payer are excluded from the template. The table below 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 Required on all COB claims with Other Coverage Code of 3, OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT, Required on all COB claims with Other Coverage Code of 2 or 4, OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER. CMS began releasing RVU information in December 2020. Health & Safety in the Home, Workplace & Outdoors, Clinical Guidelines, Standards & Quality of Care, All Health Care Professionals & Patient Safety, Elderly Pharmaceutical Insurance Coverage (EPIC) Program, Payer Specifications D.0 is also available in Portable Document Format, Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template, Response Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template, Request Claim Reversal (B2) Payer Sheet Template, Response Claim Reversal Accepted/Approved (B2) Payer Sheet Template, Response Claim Reversal Accepted/Rejected (B2) Payer Sheet Template, Response Claim Reversal Rejected/Rejected (B2) Payer Sheet Template, James V. McDonald, M.D., M.P.H., Acting Commissioner, Multisystem Inflammatory Syndrome in Children (MIS-C), Addressing the Opioid Epidemic in New York State, Health Care and Mental Hygiene Worker Bonus Program, Maternal Mortality & Disparate Racial Outcomes, Help Increasing the Text Size in Your Web Browser. Q,iDfh|)vCDD&I}nd~S&":@*DcS|]!ph);`s/EyxS5] zVHJ~4]T}+1d'R(3sk0YwIz$[))xB:H U]yno- VN1!Q`d/%a^4\+ feCDX$t]Sd?QT"I/%. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Required when text is needed for clarification or detail. Copies of all forms necessary for submitting claims are also available on the Pharmacy Resources web page of the Department's website. Dispensing (Incentive) Fee = Standard dispense fee based on a pharmacys total annual prescription volume will still apply. 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. 10 = Amount Attributed to Provider Network Selection (133-UJ) 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. endstream endobj startxref Required if Ingredient Cost Paid (506-F6) is greater than zero (0). 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG. Parenteral Nutrition Products Enrolled Medicaid fee-for-service (FFS) members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies. 03 = National Drug Code (NDC) - Formatted 11 digits (N). PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER, Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax. Each PA may be extended one time for 90 days. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Required if needed to provide a support telephone number to the receiver. Companion Document To Supplement The NCPDP VERSION The following lists the segments and fields in a Claim Billing or Claim Re-bill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Members of these eligibility categories will be subject to utilization management policies as outlined in the Appendix P, PDL or Appendix Y. Please visit the OPR section of the Department's website for more detailed information about enrollment and compliance with the Affordable Care Act. The "***" indicates that the field is repeating. Required if identification of the Other Payer Date is necessary for claim/encounter adjudication. If the reconsideration is denied, the final option is to appeal the reconsideration. Reimbursement Basis Definition Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. Required when Patient Pay Amount (505-F5) includes sales tax that is the financial responsibility of the member but is not also included in any of the other fields that add up to Patient Pay Amount. NOTE: This prior authorization override request with the Helpdesk only applies when claim records indicate that primary insurance was successfully billed first and if the medication is a covered pharmacy benefit. Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). Webb) A Basis of Cost Determination value of 08 (340B Disproportionate Share Pricing) indicates the drugs that are to be paid at the pharmacys 340B drug acquisition cost c) The drugs Actual Acquisition Cost must be entered into the Submitted Ingredient Cost field Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. An additional request for reconsideration may be submitted within 60 days of the reconsideration denial if information can be corrected or if additional supporting information is available. One of the other designators, "M", "R" or "RW" will precede it. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. A member has tried the generic equivalent but is unable to continue treatment on the generic drug and criteria is met for medication. All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. These records must be maintained for at least seven (7) years. Values other than 0, 1, 08 and 09 will deny. %%EOF Required when the patient's financial responsibility is due to the coverage gap. Required when Additional Message Information (526-FQ) is used. RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET This value is the prescription number from the first partial fill. It is used for multi-ingredient prescriptions, when each ingredient is reported. A pharmacist or pharmacist designee shall offer counseling regarding the drug therapy to each Health First Colorado member with a new or refill prescription if the pharmacist or pharmacist designee believes that it is in the best interest of the member. These medications (e.g., Paxlovid) still need to be billed to Colorado Medicaid, even though they are free of cost, and the claim requirements for billing free medications is outlined below: The Health First Colorado program uses the National Council on Prescription Drug Programs (NCPDP) electronic format and the Pharmacy Claim Form (PCF) to submit prescription drug claims. For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). 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. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. Required if Other Payer patient Responsibility Amount (352-NQ) is submitted. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. 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 AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION. Claim Billing Accepted/RejectedMaximum Count of 3 Field # 355NT 3385C3396C347C991MH 356NU992MJ142UV143UW 144UX 145UY Response Coordination of Benefits/Other Payers SegmentSegment Identification (111AM) = 28 NCPDP Field Name OTHER PAYER ID COUNT Payer Specifications D.0 B. Required when Basis of Cost Determination (432-DN) is submitted on billing. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. All necessary forms should be submitted to Magellan Rx Management at: There are four exceptions to the 120-day rule: Each of these exceptions is detailed below along with the specific instructions for submitting claims. It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. Notification of PAR approval or denial is sent to each of the following parties: In addition to stating whether the PAR has been approved or denied, a PAR denial notification letter is sent to members. Mental illness as defined in C.R.S 10-16-104 (5.5). endstream endobj 1711 0 obj <>>>/Filter/Standard/Length 128/O(V^TpFH<1b,pdk%{ \rL)/P -1052/R 4/StmF/StdCF/StrF/StdCF/U(Z6r>H8 )/V 4>> endobj 1712 0 obj <>/Metadata 104 0 R/Outlines 447 0 R/PageLayout/OneColumn/Pages 1702 0 R/StructTreeRoot 608 0 R/Type/Catalog>> endobj 1713 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1714 0 obj <>stream Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand non-preferred formulary product. This field explains how the drug ingredient cost was derived; whether DOJ, FUL, AWP (As of October 1, 2011, AWP pricing will no longer be available. Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. Companion Document To Supplement The NCPDP VERSION ", 00 = If claim is a multi-ingredient compound transaction, Required - If claim is for a compound prescription, enter "00.". 07 = Amount of Co-insurance (572-4U) The field has been designated with the situation of "Required" for the Segment in the designated Transaction. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 340B Information Exchange Reference Guide - NCPDP Access to Standards Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. If a pharmacy is made aware of eligibility after 120 days from the date of service, the pharmacy may submit the claims electronically by obtaining a PAR from the Pharmacy Support Center, or by paper using a pharmacy claim form. Required - Pharmacy's Usual and Customary Charge, Required if Other Cov Code equals 2, 3, or 4, Other Payer Patient Responsibility $ Qualifier, Required when claim is for a compound prescription, 8 = Process Compound Claim for Approved Ingredients, Conditional - Needed to process claim for approved ingredients when claim is for a compound prescription, Required when the claim is for a compound prescription. Enrolling in Health First Colorado as an OPR provider: If an OPR prescriber does not wish to enroll with Health First Colorado they must refer their patients to an enrolled prescriber, otherwise claims will deny. Download Standards Membership in NCPDP is required for access to standards. Metric decimal quantity of medication that would be dispensed for a full quantity. Required when Approved Message Code (548-6F) is used. The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. 01 = Amount Applied to Periodic Deductible (517-FH), 02 = Amount Attributed to ProductSelection/Brand Drug (134-UK), 03 = Amount Attributed to Sales Tax(523-FN), 04 = Amount Exceeding Periodic Benefit Maximum (520-FK), 06 = Patient Pay Amount (Deductible) (505-F5), 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection(135-UM), 10 = Amount Attributed to Provider Network Selection (133-UJ), 11 = Amount Attributed to Product Selection/Brand Non-Preferred FormularySelection(136-UN), 12 = Amount Attributed to Coverage Gap (137-UP), 13 = Amount Attributed to Processor Fee (571-NZ), MA = Medication Administration - use for vaccine. AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. Drugs administered in the hospital are part of the hospital fee. This letter identifies the member's appeal rights. Copies of all RAs, electronic claim rejections, and/or correspondence documenting compliance with timely filing and 60-day rule requirements must be submitted with the Request for Reconsideration. Paper claims may be submitted using a pharmacy claim form. New PAs and existing PA approvals that are less than 12 months are not eligible for deferment. Required if other payer has approved payment for some/all of the billing. The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. Colorado Pharmacy supports up to 25 ingredients. * Cough and cold products: Cough and cold products include combinations of narcotic and nonnarcotic cough suppressants, expectorants, and/or decongestants. 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. : 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.. Electronic claim submissions must meet timely filing requirements. 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. Required when there is payment from another source. DESI drugs ** [applies to drugs with a Covered Outpatient Drug (COD) status equal to DESI - 5 (LTE/IRS drug for all indications or DESI 6 LTE/IRS drug withdrawn from market)]. Required when necessary for plan benefit administration. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. Providers must submit accurate information. All claims for incremental and subsequent fills require valid values in the following fields: Please note: if a pharmacy submits a claim for a non-Schedule II medication and includes a value for quantity prescribed, it must be a valid value. Requests for timely filing waivers for extenuating circumstances must be made in writing and must contain a detailed description of the circumstance that was beyond the control of the pharmacy. Required when this value is used to arrive at the final reimbursement. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational EY Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. The following lists the segments and fields in a Claim Billing or Claim Re-bill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Required if this field could result in contractually agreed upon payment. Sent when Other Health Insurance (OHI) is encountered during claim processing. Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. Cheratussin AC, Virtussin AC). 523-FN Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. hbbd```b``} DL`D^A$KT`H2nfA H/# -~$G@3@"@*Z? Claim Billing Accepted/RejectedMaximum Count of 3 Field # 355NT 3385C3396C347C991MH 356NU992MJ142UV143UW 144UX 145UY Response Coordination of Benefits/Other Payers SegmentSegment Identification (111AM) = 28 NCPDP Field Name OTHER PAYER ID COUNT The table below Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. 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 Required when a repeating field is in error, to identify repeating field occurrence. WebThe Compound Ingredient Basis of Cost Determination field (490-UE), should equal 09 (Other) to identify the ingredient that would normally be assigned a KP modifier. For more information related to physician administered drugs and billing for this population, please visit the Physician-Administered-Drug (PAD) Billing Manual. Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQW) follows it, and the text of the following message is a continuation of the current. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL 340B Information Exchange Reference Guide - NCPDP The Health First Colorado program restricts or excludes coverage for some drug categories. Members can receive a brand name drug without a PAR if: Members may receive a brand name drug with a PAR if: The pharmacy Prior Authorization Form is available on the Pharmacy Resources web page of the Department's website. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). 1750 0 obj <>stream The total service area consists of all properties that are specifically and specially benefited. Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) To find out if a medication is a covered pharmacy benefit, refer to the Appendix P and/or the Preferred Drug List (PDL) located on the Pharmacy Resources web page. ADDITIONAL MESSAGE INFORMATION CONTINUITY. Required if a repeating field is in error, to identify repeating field occurrence. Pharmacies can submit these claims electronically or by paper. Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. 0 *Note: Code 09 is a negative amount and is not a valid option for field 351-NP. We anticipate that our pricing file updates will be completed no later than February 1, 2021. Does not mean you will be listed as a Health First Colorado provider for patient assignment or referral, Allows you to continue to see Health First Colorado members without billing Health First Colorado, and. Required when needed to specify the reason that submission of the transaction has been delayed. Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. The use of inaccurate or false information can result in the reversal of claims. If there is more than a single payer, a D.0 electronic transaction must be submitted. Required if this value is used to arrive at the final reimbursement. Incremental and subsequent fills may not be transferred from one pharmacy to another. 639 0 obj <> endobj Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. Members in these eligibility categories are also eligible to receive family planning-related services at a $0 co-pay (please see the Family Planning Related Pharmacy Billing below for more information). The Department does not pay for early refills when needed for a vacation supply. Required for the partial fill or the completion fill of a prescription. 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. A generic drug is not therapeutically equivalent to the brand name drug. If no number is supplied, populate with zeros, Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs), OCC codes 0, 1, 2, 3, and 4 Supported (no co-pay only billing allowed), COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT. 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. Required when utilization conflict is detected. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Effective 10/22/2021, Corrected formatting error; replaced "" with numeric "0", Added Real Time Prior Authorization via EHR to PAR Process, Updated to reflect billing changes to family planning and family planning-related services, Updated family planning-related section for clarity, Added primary insurance clarification to PAR Process and max day supply clarification to Dispensing Requirements, Added record maintenance requirements under Counseling, Retention of Records, and Signature Requirements, Removed requirement for providers to obtain a new override each fill for TPL/COB prior authorizations, Updated qualifier codes accepted in COB/ Other Payments under Claim Billing, Proposed rendering provider (if identified on the PAR), Non-preferred agents subject to the Preferred Drug List (PDL), Preferred agents with clinical criteria attached to the medication and all non-preferred agents subject to the Preferred Drug List (PDL) Over-the-counter (OTC) drugs that are not a regular Health First Colorado program benefit, Intravenous (IV) solutions with clinical criteria attached to the medication, Total Parenteral Nutrition (TPN) therapy and drugs, Significance of impact on the health of the Health First Colorado program population, Required monitoring of prescribing protocols to protect both the long-term efficacy of the drug and the public health, Potential for, or a history of, drug diversion and other illegal utilization, Appearance of the Health First Colorado program usage in amounts inconsistent with non- medical assistance program usage patterns, after adjusting for population characteristics, Clinical safety and efficacy compared to other drugs in that class of medications, Availability of more cost-effective comparable alternatives, Procedures where inappropriate utilization has been reported in medical literature, Performing auditing services with constant review on drug utilization. A PAR approval does not override any of the claim submission requirements. Download Standards Membership in NCPDP is required for access to standards. Non-maintenance products submitted by a pharmacy for mail-order prescriptions will deny. Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. Required on all COB claims with Other Coverage Code of 3. 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. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. Required if any other payment fields sent by the sender. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. 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. Drugs administered in clinics, these must be billed by the clinic on a professional claim. NCPDP Telecommunication Standard Version/Release #: Provider Relations Help Desk Information: NCPDP Telecommunication version 5.1 until TBD. Required when other insurance information is available for coordination of benefits. Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required.". BASIS
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