Metric decimal quantity of medication that would be dispensed for a full quantity. 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. This will allow the pharmacist to determine if the medication was prescribed in relation to a family planning visit (e.g., tobacco cessation, UTI and STI/STD medications). Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Providers can collect co-pay from the member at the time of service or establish other payment methods. %%EOF 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 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. Reimbursement Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. Billing Guidance for Pharmacists Professional and Express Scripts It is used for multi-ingredient prescriptions, when each ingredient is reported. 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. For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). 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. For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Please see the payer sheet grid below for more detailed requirements regarding each field. hbbd```b``} DL`D^A$KT`H2nfA H/# -~$G@3@"@*Z? 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. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. 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. An optional data element means that the user should be prompted for the field but does not have to enter a value. 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 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. 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. Member Contact Center1-800-221-3943/State Relay: 711. Paper claims may be submitted using a pharmacy claim form. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). ", 00 = If claim is a multi-ingredient compound transaction, Required - If claim is for a compound prescription, enter "00.". 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 The use of inaccurate or false information can result in the reversal of claims. 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). All services to women in the maternity cycle. Updated Partial Fill Section to read Incremental Fills and/or Prescription Splitting, Updated Quantity Prescribed valid value policy, Updated the diagnosis codes in COVID-19 zero copay section. Sent when Other Health Insurance (OHI) is encountered during claims processing. United States Health Information Knowledgebase Download Standards Membership in NCPDP is required for access to standards. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. Please contact the Pharmacy Support Center with questions. COVID-19 early refill overrides are not available for mail-order pharmacies. A compounded prescription (a prescription where two or more ingredients are combined to achieve a desired therapeutic effect) must be submitted on the same claim. The table below Members who are eligible for all pregnancy related and postpartum services under Medicaid are eligible to receive services for the 365- day postpartum period at a $0 co-pay. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT, Required for all COB claims with Other Coverage Code of 2 or 4. The physician is of an opinion that a transition to the generic equivalent of a brand-name drug would be unacceptably disruptive to the patient's stabilized drug regimen and criteria is met for medication. Restricted products by participating companies are covered as follows: The following are not benefits of the Health First Colorado program: The following are not pharmacy benefits of the Health First Colorado program: The pharmacy benefit manager provides a Pharmacy Support Center to handle clinical, technical, and member calls. Required when necessary to identify the Plan's portion of the Sales Tax. 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. Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. Drugs administered in a dialysis unit are part of the dialysis fee or billed on a professional claim. 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 Pharmacies should continue to rebill until a final resolution has been reached. 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. PB 18-08 340B Claim Submission Requirements and Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. not used) for this payer are excluded from the template. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. 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. Pharmacy Indicates that the drug was purchased through the 340B Drug Pricing Program. Confirm and document in writing the disposition Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. PB 18-08 340B Claim Submission Requirements and Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (402-D2) occur on the same day. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. Companion Document To Supplement The NCPDP VERSION The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 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. Source documents and source records used to create pharmacy claims shall be maintained in such a way that all electronic media claims can be readily associated and identified. 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. Access to Standards Required when Benefit Stage Amount (394-MW) is used. 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. If the claim is denied, pharmacy benefit manager will send one or more denial reason(s) that identify the problem(s). 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 The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. B. 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. The form is one-sided and requires an authorized signature. 19 Antivirals Dispensing and Reimbursement If a member calls the call center, the member will be directed to have the pharmacy call for the override. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Access to Standards Required if needed to supply additional information for the utilization conflict. This letter identifies the member's appeal rights. Enter the ingredient drug cost for each product used in making the compound. Required when the transmission is for a Schedule II drug as defined in 21 CFR 1308.12 and per CMS-0055-F (Compliance Date 9/21/2020.) Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a non-preferred formulary product. 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 Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. 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 if needed to identify the transaction. Required if a repeating field is in error, to identify repeating field occurrence. 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. The situations designated have qualifications for usage ("Required if x", "Not required if y"). Required when Basis of Cost Determination (432-DN) is submitted on billing. Access to Standards Durable Medical Equipment (DME), these must be billed as a medical benefit on a professional claim. Required if Basis of Cost Determination (432-DN) is submitted on billing. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Required on all COB claims with Other Coverage Code of 3. 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. 05 = Amount of Co-pay (518-FI) Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. The field has been designated with the situation of "Required" for the Segment in the designated Transaction. Exception for DEA Schedule II medications:Initial Incremental fills are allowed for DEA Schedule II prescription drugs dispensed to ALL members. Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER. In determining what drugs should be subject to prior authorization, the following criteria is used: Most brand-name drugs with a generic therapeutic equivalent are not covered by the Health First Colorado program. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. All products in this category are regular Medical Assistance Program benefits. COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT, 03 = Bank Information Number (BIN) Card Issuer ID. Required for partial fills. Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. 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. 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. CMS began releasing RVU information in December 2020. DESI drugs and any drug if by its generic makeup and route of administration, it is identical, related, or similar to a less than effective drug identified by the FDA, Drugs classified by the U.S.D.H.H.S. Confirm and document in writing the disposition If the original fills for these claims have no authorized refills a new RX number is required. Required - If claim is for a compound prescription, enter "0. Pharmacies may electronically rebill denied claims when the claim submission is within 120 days of the date of service. Pharmacies must call for overrides for lost, stolen, or damaged prescriptions. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT. Instructions on how to complete the PCF are available in this manual. hbbd```b``"`DrVH$0"":``9@n]bLlv #3~ ` +c For non-mail order transactions, there is a maximum 20-day accumulation allowed every rolling 180 days. Reimbursement Basis Definition ADDITIONAL MESSAGE INFORMATION CONTINUITY. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Required when a patient selected the brand drug and a generic form of the drug was available. Required if Basis of Cost Determination (432-DN) is submitted on billing. BNR=Brand Name Required), claim will pay with DAW9. PARs are reviewed by the Department or the pharmacy benefit manager. Members within this eligibility category are only eligible to receive family planning and family planning-related medication. 0 Mental illness as defined in C.R.S 10-16-104 (5.5). Required when needed to provide a support telephone number. Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. Express Scripts Billing Guidance for Pharmacists Professional and This document contains the specifications of six templates: Payer: Please list each transaction supported with the segments, fields and pertinent information on each transaction. 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. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. 1750 0 obj <>stream Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). iT|'r4O!JtN!EIVJB yv7kAY:@>1erpFBkz.cDEXPTo|G|r>OkWI/"j1;gT* :k $O{ftLZ>T7h.6k>a'vh?a!>7 s No products in the category are Medical Assistance Program benefits. 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. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0).
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