Required if this field is reporting a contractually agreed upon payment. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Flat Sales Tax Amount Paid (558-AW) is greater than zero (0). Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational An emergency is any condition that is life-threatening or requires immediate medical intervention. Parenteral Nutrition Products 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 More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Required if Other Payer ID (340-7C) is used. 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. If the claim is denied, pharmacy benefit manager will send one or more denial reason(s) that identify the problem(s). Note: Fields that are not used in the Claim Billing/Claim Re-bill transactions and those that do not have qualified requirements (.i.e., not used) for this payer are excluded from the template. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. ), SMAC, WAC, or AAC. Required when needed to provide a support telephone number. Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. 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. Representation by an attorney is usually required at administrative hearings. The resubmitted request must be completed in the same manner as an original reconsideration request. The procedure to request a PAR and the medications that require a PAR are outlined in Appendix P - Pharmacy Benefit Prior Authorization Procedures and Criterialocated in the Pharmacy Prior Authorization Policies section of the Department's website. United States Health Information Knowledgebase Billing Guidance for Pharmacists Professional and 06 = Patient Pay Amount (505-F5) 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. 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 A generic drug is not therapeutically equivalent to the brand name drug. Required when a repeating field is in error, to identify repeating field occurrence. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT. Prescription cough and cold products for all ages will not require prior authorization for Health First Colorado members. 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. All electronic claims must be submitted through a pharmacy switch vendor. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. This value is the prescription number from the first partial fill. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). A member has tried the generic equivalent but is unable to continue treatment on the generic drug and criteria is met for medication. 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. Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill). PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER, Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Reimbursement Rates for 2021 Procedure Codes Drug used for erectile or sexual dysfunction. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). %PDF-1.5 % Does not obligate you to see Health First Colorado members. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORMULARY SELECTION. All products in this category are regular Medical Assistance Program benefits. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. 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. 340B Information Exchange Reference Guide - NCPDP Please contact the Pharmacy Support Center for a one-time PA deferment. Required if Basis of Cost Determination (432-DN) is submitted on billing. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. 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 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. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. ), SMAC, WAC, or AAC. AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Reimbursement Basis Definition 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Pharmacies may electronically rebill denied claims when the claim submission is within 120 days of the date of service. 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. Required if Other Payer patient Responsibility Amount (352-NQ) is submitted. Pharmacies should retrieve their Remittance Advice (RA) or X12N 835 through the Provider Web Portal. A PAR is only necessary if an ingredient in the compound is subject to prior authorization. CMS began releasing RVU information in December 2020. For non-scheduled drugs, 75 percent of the days' supply of the last fill must lapse before a drug can be filled again. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Health First Colorado is temporarily deferring medication prior authorization (PA) requirements for members on all medications for which there is an existing 12-month PA approval in place. Required if needed to supply additional information for the utilization conflict. The situations designated have qualifications for usage ("Required when x,"Not Required when y"). Physicians and other practitioners who order, prescribe or refer items or services for Health First Colorado members, but who choose not to submit claims to Health First Colorado, are referred to as OPR providers. If the member does not pick up the prescription from the pharmacy within 14 calendar days, the prescription must be reversed on the 15th calendar day. The use of inaccurate or false information can result in the reversal of claims. Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. Required if the identification to be used in future transactions is different than what was submitted on the request. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. Claims that cannot be submitted through the vendor must be submitted on paper. Updates made throughout related to the POS implementation under Magellan Rx Management. Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. Testing Procedures - Alabama Medicaid The following NCPDP fields below will be required on 340B transactions. Confirm and document in writing the disposition If a member calls the call center, the member will be directed to have the pharmacy call for the override. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. WebEmergencyOverride code 324-CO Patient State/Province Address ; RW : Required for some federal programs, when submitting SalesTax, or EmergencyOverride code 325-CP Patient Zip/Postal Zone; R: Required for some federal programs, when submitting SalesTax, or EmergencyOverride code 37-C7 Place of Service; RW : Required when necessary for plan Additionally, all providers entering 340B claims must be registered and active with HRSA. Companion Document To Supplement The NCPDP VERSION Quantity Prescribed (Field # 460-ET) for ALL DEA Schedule II prescription drugs, regardless of incremental or full-quantity fills, Quantity Intended To Be Dispensed (Field # 344-HF), Days Supply Intended To Be Dispensed (Field # 345-HG). Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. Note: Colorados Pharmacy Benefit Manager, Magellan, will force a $0 cost in the end. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. Payer Specifications D.0 Required for the partial fill or the completion fill of a prescription. PB 18-08 340B Claim Submission Requirements and If the medication has been determined to be family planning or family planning-related, it should be documented in the prescription record. Drugs administered in the hospital are part of the hospital fee. Please contact the Pharmacy Support Center with questions. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Pharmacy employee negligence, employer failure to provide sufficient, well-trained employees, or failure to properly monitor the activities of employees and agents (e.g., billing services) are not considered extenuating circumstances beyond the pharmacy provider's control. Required when specified in trading partner agreement. Required if Other Payer Amount Paid (431-Dv) is used. Pharmacies must call for overrides for lost, stolen, or damaged prescriptions. Express Scripts The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication. Billing Guidance for Pharmacists Professional and Product may require PAR based on brand-name coverage. May be used for cases where Health First Colorado's drug list designates both a brand drug and its generic equivalent as non-preferred products and also designates that the non-preferred brand product is favored for coverage over the equivalent non-preferred generic. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). 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 The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. Please refer to the specific rules and requirements regarding electronic and paper claims below. 1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads. This letter identifies the member's appeal rights. Express Scripts The following claims can be submitted on paper and processed for payment: Providers can submit only one claim per submission on the PCF, however, compound claims can be submitted. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. WebExamples of Reimbursable Basis in a sentence. The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. 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 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. 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Claims that do not result in the Health First Colorado program authorizing reimbursement for services rendered may be resubmitted. Required when Preferred Product ID (553-AR) is used. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. The field is mandatory for the Segment in the designated Transaction. Indicates that the drug was purchased through the 340B Drug Pricing Program. Interactive claim submission must comply with Colorado D.0 Requirements. United States Health Information Knowledgebase Required if needed to provide a support telephone number of the other payer to the receiver. 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. Amount expressed in metric decimal units of the product included in the compound. %%EOF CMS began releasing RVU information in December 2020. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. Required when a patient selected the brand drug and a generic form of the drug was available. BASIS OF CALCULATION - PERCENTAGE SALES TAX. Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate Program. The form is one-sided and requires an authorized signature. 12 = Amount Attributed to Coverage Gap (137-UP) Required when the customer is responsible for 100 percent of the prescription payment and when the provider net sale is less than the amount the customer is expected to pay. 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. Provided for informational purposes only. WebExamples of Reimbursable Basis in a sentence. Electronic claim submissions must meet timely filing requirements. Required when Other Payer ID (340-7C) is used. Medication Requiring PAR - Update to Over-the-counter products. 523-FN All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational 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. =y?@d:qb@6l7YC&)H]zjse/0 m{YSqT;?z~bDG_agiZo8pomle;]Zt QmF8@bt/ &|=SM1LZTr'hxu&0\lcmUFC!BKXrT} 7IFD&t{TagKwRI>T$ wja 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. In an emergency, when a PAR cannot be obtained in time to fill the prescription, pharmacies may dispense a 72-hour supply (3 days) of covered outpatient prescription drugs to an eligible member by calling the Pharmacy Support Center. 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 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 Basis Definition Delayed notification to the pharmacy of eligibility. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc. If the original fills for these claims have no authorized refills a new RX number is required. Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. IV equipment (for example, Venopaks dispensed without the IV solutions). Required if Previous Date Of Fill (530-FU) is used. endstream endobj startxref Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. Member's 7-character Medical Assistance Program ID. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. We anticipate that our pricing file updates will be completed no later than February 1, 2021. Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. The offer to counsel shall be face-to-face communication whenever practical or by telephone. It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. 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. Required for partial fills. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. Required if Other Payer Amount Paid Qualifier (342-HC) is used. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). %PDF-1.6 % 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. 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) The maternity cycle is the time period during the pregnancy and 365days' post-partum. 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. Maternal, Child and Reproductive Health billing manual web page. Download Standards Membership in NCPDP is required for access to standards. Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. Required when necessary to identify the Patient's portion of the Sales Tax. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL Required if utilization conflict is detected. Required if Other Payer Reject Code (472-6E) is used. Required when Approved Message Code (548-6F) is used. 523-FN 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 Previous Date Of Fill (530-FU) is used. Timely filing for electronic and paper claim submission is 120 days from the date of service. Required when necessary to identify the Plan's portion of the Sales Tax. 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. Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Required when Basis of Cost Determination (432-DN) is submitted on billing. United States Health Information Knowledgebase The standard drug ingredient reimbursement methodology applies to the quantity dispensed with each fill. Required if Other Amount Claimed Submitted (480-H9) is greater than zero (0). Required when this value is used to arrive at the final reimbursement. 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. The field has been designated with the situation of "Required" for the Segment in the designated Transaction. "Required when." 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. If reversal is for multi-ingredient prescription, the value must be 00. Sent when claim adjudication outcome requires subsequent PA number for payment. 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 Mental illness as defined in C.R.S 10-16-104 (5.5). Pharmacies may use the number 8 in Field # 420-DK instead of obtaining a PA for non-covered ingredients to allow the claim to pay for the ingredients that are considered a covered benefit. COMPOUND INGREDIENT BASIS OF COST DETERMINATION. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits, 3 = Other Coverage Billed Claim not Covered. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. 20 = 340B - Indicates that, prior to providing service, the pharmacy has determined the product being billed is purchased pursuant to rights available under Section 340B of the Public Health Act of 1992 including sub-ceiling purchases authorized by Section 340B (a) (10) and those made through the Prime Vendor Program (Section 340B(a)(8)).