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. 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 Required if Reason for Service Code (439-E4) is used. Required if needed to provide a support telephone number of the other payer to the receiver. 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. We anticipate that our pricing file updates will be completed no later than February 1, 2021. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. All products in this category are regular Medical Assistance Program benefits. Metric decimal quantity of medication that would be dispensed for a full quantity. When a pharmacy has exhausted all authorized rebilling procedures and has not been paid for a claim, the pharmacy may submit a Request for Reconsideration to the pharmacy benefit manager. Does not obligate you to see Health First Colorado members. Timely filing for electronic and paper claim submission is 120 days from the date of service. Required to identify the actual group that was used when multiple group coverage exist. Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. "C" indicates the completion of a partial fill. '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits, 3 = Other Coverage Billed Claim not Covered. Interactive claim submission must comply with Colorado D.0 Requirements. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Required if Other Payer ID (340-7C) is used. Required when Patient Pay Amount (505-F5) includes deductible. 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. Health First Colorado is the payer of last resort. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. We anticipate that our pricing file updates will be completed no later than February 1, 2021. 639 0 obj <> endobj B. The table below 523-FN Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. Colorado Pharmacy supports up to 25 ingredients. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. 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. Maternal, Child and Reproductive Health billing manual web page. Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Confirm and document in writing the disposition 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. Members in this eligibility category may receive up to a 12-month supply ofcontraceptiveswith a $0 co-pay. Please refer to the specific rules and requirements regarding electronic and paper claims below. It is used when a sender notifies the receiver of drug utilization, drug evaluations, or information on the appropriate selection to process the claim/encounter. 523-FN Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate Program. Notification of PAR approval or denial is sent to each of the following parties: In addition to stating whether the PAR has been approved or denied, a PAR denial notification letter is sent to members. Required if utilization conflict is detected. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. Members of these eligibility categories will be subject to utilization management policies as outlined in the Appendix P, PDL or Appendix Y. All electronic claims must be submitted through a pharmacy switch vendor. 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 if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. Required when its value has an effect on the Gross Amount Due (430-DU) calculation. Values other than 0, 1, 08 and 09 will deny. 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. The situations designated have qualifications for usage ("Required when x,"Not Required when y"). Required for partial fills. The claim may be a multi-line compound claim. Required when a product preference exists that needs to be communicated to the receiver via an ID. 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 The offer to counsel shall be face-to-face communication whenever practical or by telephone. Indicates that the drug was purchased through the 340B Drug Pricing Program. The field has been designated with the situation of "Required" for the Segment in the designated Transaction. Provided for informational purposes only. 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. Required when Previous Date Of Fill (530-FU) is used. Required for this program when the Other Coverage Code (308-C8) of "3" is used. Sent when Other Health Insurance (OHI) is encountered during claim processing. 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 When." Claims that do not result in the Health First Colorado program authorizing reimbursement for services rendered may be resubmitted. 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/%. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. Required when Other Amount Paid (565-J4) is used. 1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads. It is used for multi-ingredient prescriptions, when each ingredient is reported. 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. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT, Required for all COB claims with Other Coverage Code of 2 or 4. Required if Help Desk Phone Number (550-8F) is used. For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. Required for partial fills. 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. INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT. 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 Members within this eligibility category are only eligible to receive family planning and family planning-related medication. 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 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. Member's 7-character Medical Assistance Program ID. Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. 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 Incremental and subsequent fills may not be transferred from one pharmacy to another. Required when Basis of Cost Determination (432-DN) is submitted on billing. Required when Other Amount Claimed Submitted (480-H9) is used. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational For non-mail order transactions, there is a maximum 20-day accumulation allowed every rolling 180 days. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. Required when Basis of Cost Determination (432-DN) is submitted on billing. CMS began releasing RVU information in December 2020. Required when Other Payer ID (340-7C) is used. Effective 10/22/2021, Updated policy for Quantity Limit overrides in COVID-19 section. Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. Required when there is payment from another source. Providers must submit accurate information. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). 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 Sent when claim adjudication outcome requires subsequent PA number for payment. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. This pharmacy billing manual explains many of the Colorado Department of Health Care Policy & Financing's (the Department) policies regarding billing, provider responsibilities, and program benefits. 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. NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Pharmacies are expected to keep records indicating when member counseling was not or could not be provided. 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). 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 Figure 4.1.3.a. 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. Cheratussin AC, Virtussin AC). EY COMPOUND INGREDIENT BASIS OF COST DETERMINATION. Required - If claim is for a compound prescription, enter "0. enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. Effective February 25, 2017, pharmacies must code their systems using the D.0 Payer Sheets provided below when submitting pharmacy POS transactions to the Health First Colorado program for payment. Required if other payer has approved payment for some/all of the billing. 523-FN In no case, shall prescriptions be kept in will-call status for more than 14 days. For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility. Date of service for the Associated Prescription/Service Reference Number (456-EN). %%EOF All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. B. The "Dispense as Written (DAW) Override Codes" table describes the valid scenarios allowable per DAW code. The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. Figure 4.1.3.a. The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. * Cough and cold products: Cough and cold products include combinations of narcotic and nonnarcotic cough suppressants, expectorants, and/or decongestants. Updates made throughout related to the POS implementation under Magellan Rx Management. 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). Please see the payer sheet grid below for more detailed requirements regarding each field. 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 A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Representation by an attorney is usually required at administrative hearings. *Note: Code 09 is a negative amount and is not a valid option for field 351-NP. Required when any other payment fields sent by the sender. 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 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. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). New PAs and existing PA approvals that are less than 12 months are not eligible for deferment. For TXIX, if the prescriber confirms that the drug was not prescribed in relation to a family planning visit, then the pharmacy should remove the 6-Family Plan from the claim so that the claim can adjudicate accordingly. Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. Required when other insurance information is available for coordination of benefits. 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. 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. Only members have the right to appeal a PAR decision. Sent when DUR intervention is encountered during claim processing. 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. PARs are reviewed by the Department or the pharmacy benefit manager. The situations designated have qualifications for usage ("Required if x", "Not required if y"). 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 the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). 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. Drug used for erectile or sexual dysfunction. 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 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. The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. If there is more than a single payer, a D.0 electronic transaction must be submitted. Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. 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. 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. DESI drugs ** [applies to drugs with a Covered Outpatient Drug (COD) status equal to DESI - 5 (LTE/IRS drug for all indications or DESI 6 LTE/IRS drug withdrawn from market)]. Required if Approved Message Code (548-6F) is used. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. 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. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. If the reconsideration is denied, the final option is to appeal the reconsideration. Claims that cannot be submitted through the vendor must be submitted on paper. Cost-sharing for members must not exceed 5% of their monthly household income. Enrolling in Health First Colorado as an OPR provider: If an OPR prescriber does not wish to enroll with Health First Colorado they must refer their patients to an enrolled prescriber, otherwise claims will deny. 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. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG. 05 = Amount of Co-pay (518-FI) Approval of a PAR does not guarantee payment. 03 = National Drug Code (NDC) - Formatted 11 digits (N). WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. "Required when." If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax. 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. Confirm and document in writing the disposition 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. Required if Previous Date of Fill (530-FU) is used. Required when Other Payer-Patient Responsibility Amount (352-NQ) is used. 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 7.5 percent tolerance is allowed between fills for Synagis. Required when necessary for patient financial responsibility only billing. Required if text is needed for clarification or detail. WebExamples of Reimbursable Basis in a sentence. No blanks allowed. 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 if Additional Message Information (526-FQ) is used. Required if Patient Pay Amount (505-F5) includes co-pay as patient financial responsibility. Required if Patient Pay Amount (505-F5) includes deductible. 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. 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. A PAR is only necessary if an ingredient in the compound is subject to prior authorization. Prior authorization requests for some products may be approved based on medical necessity. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency.
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