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 1727 0 obj
<>/Encrypt 1711 0 R/Filter/FlateDecode/ID[]/Index[1710 41]/Info 1709 0 R/Length 94/Prev 551050/Root 1712 0 R/Size 1751/Type/XRef/W[1 3 1]>>stream
Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational The field has been designated with the situation of "Required" for the Segment in the designated Transaction. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) 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. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. BASIS The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. 12 = Amount Attributed to Coverage Gap (137-UP)
639 0 obj
<>
endobj
The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. Pharmacy Reimbursement Rates for 2021 Procedure Codes 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 "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. The Department does not pay for early refills when needed for a vacation supply. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Prescription cough and cold products for all ages will not require prior authorization for Health First Colorado members. Required for 340B Claims. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program. Required on all COB claims with Other Coverage Code of 2. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. A member has tried the generic equivalent but is unable to continue treatment on the generic drug and criteria is met for medication. Required if Reason for Service Code (439-E4) is used. Required when a patient selected the brand drug and a generic form of the drug was available. * Cough and cold products: Cough and cold products include combinations of narcotic and nonnarcotic cough suppressants, expectorants, and/or decongestants. New PAs and existing PA approvals that are less than 12 months are not eligible for deferment. 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. Member's 7-character Medical Assistance Program ID. The Health First Colorado program restricts or excludes coverage for some drug categories. INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT. If a member calls the call center, the member will be directed to have the pharmacy call for the override. B. WebExamples of Reimbursable Basis in a sentence. DISPENSING FEE CONTRACTED/REIMBURSABLE AMOUNT. Reimbursement 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. Required when its value has an effect on the Gross Amount Due (430-DU) calculation. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. "P" indicates the quantity dispensed is a partial fill. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Required when a product preference exists that either cannot be communicated by the Preferred Product ID (553-AR) or to clarify the Preferred Product ID (553-AR). We anticipate that our pricing file updates will be completed no later than February 1, 2021. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. 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. Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. 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. Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim. 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 pharmacy benefit manager processes both electronic and paper claims and provides claim, provider, eligibility, and PAR interfaces with the Medicaid Management Information System (MMIS). Billing Guidance for Pharmacists Professional and 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. Providers must submit accurate information. If the original fills for these claims have no authorized refills a new RX number is required. 0
BASIS OF CALCULATION - PERCENTAGE SALES TAX. The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication. Required if Patient Pay Amount (505-F5) includes co-pay as patient financial responsibility. 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. Required when Other Payer ID (340-7C) is used. Providers who consistently submit five or fewer claims per month, Claims that are more than 120 days from the date of service that require special attachments, and, 2 = Other coverage exists - payment collected, 3 = Other coverage exists - this claim not covered, 4 = Other coverage exists - payment not collected, Required when submitting a claim for member w/ other coverage, 1 = Substitution Not Allowed by Prescriber, 8 = Substitution Allowed - Generic Drug Not Available in Marketplace, 9 = Substitution Allowed by Prescriber but Plan Requests Brand. Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). 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 If PAR is authorized, claim will pay with DAW1. Required when Basis of Cost Determination (432-DN) is submitted on billing. Requests for Reconsideration must be filed in writing with the pharmacy benefit manager within 60 days of the most recent claim or prior reconsideration denial. 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. WebExamples of Reimbursable Basis in a sentence. For non-mail order transactions, there is a maximum 20-day accumulation allowed every rolling 180 days. Nursing facilities must furnish IV equipment for their patients. 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. If a pharmacy disagrees with the final decision of the pharmacy benefit manager, the pharmacy may file an appeal with the Office of Administrative Courts. Parenteral Nutrition Products Reimbursement The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. Required when needed to provide a support telephone number of the other payer to the receiver. Reimbursement Rates for 2021 Procedure Codes These will be handled on a case-by-case basis by the Pharmacy Support Center if requested by a Health First Colorado healthcare professional (i.e. Required when Patient Pay Amount (505-F5) includes deductible. 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. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. Amount expressed in metric decimal units of the product included in the compound. Required when Help Desk Phone Number (550-8F) is used. Reversal Window (If transaction is billed today, what is the, Required when needed to match the reversal to the original billing transaction. Companion Document To Supplement The NCPDP VERSION Required if Basis of Cost Determination (432-DN) is submitted on billing. Required when Basis of Cost Determination (432-DN) is submitted on billing. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Pharmacies that have an electronic tracking system shall review prescriptions in will-call status on a daily basis and enter a reversal of prescriptions not picked up within 10 days of billing. 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. PB 18-08 340B Claim Submission Requirements and Required if this field could result in contractually agreed upon payment. Required if needed to match the reversal to the original billing transaction. If a Medicaid member enters or leaves a nursing facility, the member may require a refill-too-soon override in order to receive his or her drugs. Download Standards Membership in NCPDP is required for access to standards. Required when there is payment from another source. 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 Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. 06 = Patient Pay Amount (505-F5) 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 Claims that cannot be submitted through the vendor must be submitted on paper. Drug used for erectile or sexual dysfunction. Required when Basis of Cost Determination (432-DN) is submitted on billing. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. Required to identify the actual group that was used when multiple group coverage exist. Caremark The PCF should be submitted to Magellan Rx Management agent at: Below are the completion instructions for the Colorado Pharmacy Claim Form (PCF-2) for Pharmacy Providers. Sent when Other Health Insurance (OHI) is encountered during claims processing. Required if Other Payer Reject Code (472-6E) is used. 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. 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. Updated Lost/Stolen/Damaged/Vacation Prescriptions section - police report is no longer required for Stolen Medications, PAR Process: Updated notification letter section, Partial Fills and/or Prescription: Updated partial fill criteria, Updated contact information on page 15, to include Magellan's helpdesk info. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). 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. Required if other insurance information is available for coordination of benefits. These values are for covered outpatient drugs. 03 = National Drug Code (NDC) - Formatted 11 digits (N). Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Companion Document To Supplement The NCPDP VERSION Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. ), SMAC, WAC, or AAC. Download Standards Membership in NCPDP is required for access to standards. The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 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 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. Timely filing for electronic and paper claim submission is 120 days from the date of service. Required if Basis of Cost Determination (432-DN) is submitted on billing. 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. Cost-sharing for members must not exceed 5% of their monthly household income. 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. Express Scripts Only members have the right to appeal a PAR decision. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Each PA may be extended one time for 90 days. 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. Required when there is a known patient financial responsibility incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). 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. Caremark Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. 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. 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. Indicates that the drug was purchased through the 340B Drug Pricing Program. 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. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. Required if identification of the Other Payer Date is necessary for claim/encounter adjudication. Required when Compound Ingredient Modifier Code (363-2H) is sent. Values other than 0, 1, 08 and 09 will deny. 0
1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). 81J
_FLy4AyGP(O
OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER. 13 = Amount Attributed to Processor Fee (571-NZ). For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).