PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER, ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) 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. 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 any other payment fields sent by the sender. If the timely filing period expires due to a delayed or back-dated member eligibility determination, the claim is considered timely if received within 120 days from the date the member was granted backdated eligibility. Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Required when Basis of Cost Determination (432-DN) is submitted on billing. A PAR approval does not override any of the claim submission requirements. For the expanded income group, if the prescriber confirms that the drug was not prescribed in relation to a family planning visit, then it will be denied. Download Standards Membership in NCPDP is required for access to standards. Required when Additional Message Information (526-FQ) is used. EY Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. WebExamples of Reimbursable Basis in a sentence. Pharmacies can submit these claims electronically or by paper. Members who were formerly in foster care are co-pay exempt until their 26th birthday, Services provided by Community Mental Health Services, Members receiving a prescription for Tobacco Cessation Product. SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). endstream endobj startxref The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication. WebExamples of Reimbursable Basis in a sentence. Signature requirements are temporarily waived for Member Counseling and Proof of Delivery. Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Required if Basis of Cost Determination (432-DN) is submitted on billing. Required if and only if 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. Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. Medication Requiring PAR - Update to Over-the-counter products. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. 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. 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 Please refer to the specific rules and requirements regarding electronic and paper claims below. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional %%EOF All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. %PDF-1.5 % Required when necessary for patient financial responsibility only billing. If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax. Updates made throughout related to the POS implementation under Magellan Rx Management. These records must be maintained for at least seven (7) years. hbbd```b``"`DrVH$0"":``9@n]bLlv #3~ ` +c Providers must submit accurate information. Other Payer Bank Information Number (BIN). 07 = Amount of Co-insurance (572-4U) The field has been designated with the situation of "Required" for the Segment in the designated Transaction. Required when necessary to identify the Plan's portion of the Sales Tax. Required when Help Desk Phone Number (550-8F) is used. Required if utilization conflict is detected. Drugs administered in the hospital are part of the hospital fee. Required if other payer has approved payment for some/all of the billing. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. 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. Figure 4.1.3.a. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Health First Colorado is waiving co-pay amounts for medications related to COVID-19 when ICD-10 diagnosis code U07.1, U09.9, Z20.822, Z86.16, J12.82, Z11.52, B99.9, J18.9, Z13.9, M35.81, M35.89, Z11.59, U07.1, B94.8, O98.5, Z20.818, Z20.828, R05, R06.02, or R50.9 is entered on the claim transmittal. Enter the ingredient drug cost for each product used in making the compound. NCPDP Telecommunication Standard Version/Release #: Provider Relations Help Desk Information: NCPDP Telecommunication version 5.1 until TBD. 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. Required when Basis of Reimbursement Determination (522-FM) is "14" (Patient Responsibility Amount) or "15" (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill). New PAs and existing PA approvals that are less than 12 months are not eligible for deferment. 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 Pharmacies should continue to rebill until a final resolution has been reached. Required if Other Amount Claimed Submitted (480-H9) is greater than zero (0). 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. NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. 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 Services cannot be withheld if the member is unable to pay the co-pay. Required when needed to provide a support telephone number. Required when Flat Sales Tax Amount Submitted (481-HA) is greater than zero (0) or when Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement. Drugs administered in clinics, these must be billed by the clinic on a professional claim. 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. All services to women in the maternity cycle. The following NCPDP fields below will be required on 340B transactions. Members in this eligibility category may receive up to a 12-month supply ofcontraceptiveswith a $0 co-pay. 05 = Amount of Co-pay (518-FI) 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. Paper claims may be submitted using a pharmacy claim form. Basis of Cost Determination = This is not a required field on the claim, but 05 (Acquisition) or 08 (340B/Disproportionate Share Pricing/Public Health Service) will be accepted if submitted on the claim. 1-5 = Refill number - Number of the replenishment, 8 = Substitution Allowed-Generic Drug Not Available in Marketplace, 1-99 = Authorized Refill number - with 99 being as needed, refills unlimited, 8 = Process Compound For Approved Ingredients. Required for partial fills. An optional data element means that the user should be prompted for the field but does not have to enter a value. B. Required for 340B Claims. Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. 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. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. Required when needed for receiver claim determination when multiple products are billed. Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. 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. Please contact the Pharmacy Support Center with questions. Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. If PAR is authorized, claim will pay with DAW1. 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 Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. 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 Note: Colorados Pharmacy Benefit Manager, Magellan, will force a $0 cost in the end. ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. 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. COVID-19 early refill overrides are not available for mail-order pharmacies. For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). %%EOF 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 OTHER PAYER - PATIENT RESPONSIBILITY AMOUNT COUNT, Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used, OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFER, Required if Other Payer-Patient Responsibility Amount (352-NQ) is used352-NQ. Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. Health First Colorado does not provide reimbursement for products by manufacturers that have not signed a rebate agreement unless the Department has made a determination that the availability of the drug is essential, such drug has been given 1-A rating by the Food and Drug Administration (FDA), and prior authorized. For DAW 8-generic not available in marketplace or DAW 9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Patient Requested Product Dispensed. We anticipate that our pricing file updates will be completed no later than February 1, 2021. Members that meet their monthly co-pay maximum, or 5% of their monthly household income, will be exempt from co-pay for the remainder of that month. 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 If there is more than a single payer, a D.0 electronic transaction must be submitted. Colorado Pharmacy supports up to 25 ingredients. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. 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. Single agent antihistamines and their combination products with a decongestant are not considered to be cough and cold products and are regular Medical Assistance Program benefits. 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. Required when needed to specify the reason that submission of the transaction has been delayed. Required if needed to provide a support telephone number of the other payer to the receiver. 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. Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate Program. *Note: Code 09 is a negative amount and is not a valid option for field 351-NP. Approval of a PAR does not guarantee payment. Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility. Sent if reversal results in generation of pricing detail.
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