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 endstream endobj startxref Required if Other Payer Amount Paid (431-Dv) is used. Pharmacies must complete third-party information on the PCF and submit documentation from the third-party payer of payment or lack of payment. 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). Required if Basis of Cost Determination (432-DN) is submitted on billing. 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. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional 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. Pharmacy 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. 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. Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. 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 Paper claims may be submitted using a pharmacy claim form. "Required When." The number of authorized refills must be consistent with the original paid claim for all subsequent refills. The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). 05 = Amount of Co-pay (518-FI) Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. This requirement stems from the Social Security Act, 42 U.S.C. Required when specified in trading partner agreement. 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). 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. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. Pharmacies are expected to keep records indicating when member counseling was not or could not be provided. 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 Required when Submission Clarification Code (420-DK) is used. 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. 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. 06 = Patient Pay Amount (505-F5) Web*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 Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. 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. Drugs administered in the hospital are part of the hospital fee. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). We anticipate that our pricing file updates will be completed no later than February 1, 2021. Companion Document To Supplement The NCPDP VERSION A 7.5 percent tolerance is allowed between fills for Synagis. Required if Other Payer patient Responsibility Amount (352-NQ) is submitted. 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 Providers can collect co-pay from the member at the time of service or establish other payment methods. 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. Required when Approved Message Code (548-6F) is used. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. 1750 0 obj <>stream The form is one-sided and requires an authorized signature. A member has tried the generic equivalent but is unable to continue treatment on the generic drug and criteria is met for medication. B. NCPDP EC 22-M/I DISPENSE AS WRITTEN CODE~50021~ERROR LIST M/I DISPENSE AS WRITTEN CODE and return the supplemental message Submitted DAW code not supported. 523-FN Substitution Allowed - Pharmacist Selected Product Dispensed, NCPDP 22-M/I DISPENSE AS WRITTEN CODE~50021~ERROR LIST M/I DISPENSE AS WRITTEN CODE and return the supplemental message Submitted DAW code not supported. Required when Other Amount Paid (565-J4) is used. 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 Helpdesk is available 24 hours a day, seven days a week. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational 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. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. The field is mandatory for the Segment in the designated Transaction. Payer Specifications D.0 Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Required when this value is used to arrive at the final reimbursement. PB 18-08 340B Claim Submission Requirements and For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. 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. CMS began releasing RVU information in December 2020. 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. Provided for informational purposes only. The use of inaccurate or false information can result in the reversal of claims. 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. endstream endobj startxref hbbd```b``"`DrVH$0"":``9@n]bLlv #3~ ` +c hb```+@(1Q(b!V R;Wyjn~u~kw~}CI @B 8F8CEVR,r@Zk0226H;)maVf\p@j053s0OIk5v X u cs. "P" indicates the quantity dispensed is a partial fill. WebThe Compound Ingredient Basis of Cost Determination field (490-UE), should equal 09 (Other) to identify the ingredient that would normally be assigned a KP modifier. 661 0 obj <>/Filter/FlateDecode/ID[<62EB3A7657CA4643BE855C13B68E8087>]/Index[639 39]/Info 638 0 R/Length 107/Prev 799058/Root 640 0 R/Size 678/Type/XRef/W[1 3 1]>>stream Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). Billing Guidance for Pharmacists Professional and Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. Indicates that the drug was purchased through the 340B Drug Pricing Program. Required - If claim is for a compound prescription, list total # of units for claim. Required when needed to provide a support telephone number. Required when Other Payer-Patient Responsibility Amount (352-NQ) is used. Timely filing for electronic and paper claim submission is 120 days from the date of service. Q,iDfh|)vCDD&I}nd~S&":@*DcS|]!ph);`s/EyxS5] zVHJ~4]T}+1d'R(3sk0YwIz$[))xB:H U]yno- VN1!Q`d/%a^4\+ feCDX$t]Sd?QT"I/%. Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. 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 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. The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. EY Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. Required when Reason For Service Code (439-E4) is used. RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET Required if Patient Pay Amount (505-F5) includes deductible. Required when Ingredient Cost Paid (506-F6) is greater than zero (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. 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). 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. Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. Sent when DUR intervention is encountered during claim adjudication. Cost-sharing for members must not exceed 5% of their monthly household income. 19 Antivirals Dispensing and Reimbursement The resubmitted request must be completed in the same manner as an original reconsideration request. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. 12 = Amount Attributed to Coverage Gap (137-UP) 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. RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET COVID-19 medications that were procured by the federal government are free of cost to pharmacy providers. If the original fills for these claims have no authorized refills a new RX number is required. Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim. 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. 03 = National Drug Code (NDC) - Formatted 11 digits (N). If a member calls the call center, the member will be directed to have the pharmacy call for the override. Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. 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. 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. 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. Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Required if Help Desk Phone Number (550-8F) is used. 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. Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. 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. The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website. 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. Electronic claim submissions must meet timely filing requirements. The total service area consists of all properties that are specifically and specially benefited. Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. Medication Requiring PAR - Update to Over-the-counter products. 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. Nursing facilities must furnish IV equipment for their patients. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. Confirm and document in writing the disposition Required if necessary as component of Gross Amount Due. Member's 7-character Medical Assistance Program ID. ), SMAC, WAC, or AAC. 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 needed to provide a support telephone number of the other payer to the receiver. 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. Appeals may be sent to: With few exceptions, providers are required to submit claims electronically. Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. 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. United States Health Information Knowledgebase WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and 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 Reversal Window (If transaction is billed today, what is the, Required when needed to match the reversal to the original billing transaction. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug.
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