Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. 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 must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. Added Temporary COVID section, updated Provider Web Portal link, Updated verbiage to include the NCPDP D.0 guidelines for field 460-ET, Updated DAW Codes: Updated Dispense as Written (DAW) Override Code table. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. The Field is mandatory for the Segment in the designated Transaction. If reversal is for multi-ingredient prescription, the value must be 00. enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). Required when Basis of Cost Determination (432-DN) is submitted on billing. A 7.5 percent tolerance is allowed between fills for Synagis. The offer to counsel shall be face-to-face communication whenever practical or by telephone. 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. 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. Does not obligate you to see Health First Colorado members. 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 Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. 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. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. 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. Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). It is used for multi-ingredient prescriptions, when each ingredient is reported. Required if this value is used to arrive at the final reimbursement. Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). The use of inaccurate or false information can result in the reversal of claims. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. Medication Requiring PAR - Update to Over-the-counter products. 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 when utilization conflict is detected. 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/%. Pharmacies may electronically rebill denied claims when the claim submission is within 120 days of the date of service. 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. ), SMAC, WAC, or AAC. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Required if Previous Date of Fill (530-FU) is used. Only members have the right to appeal a PAR decision. 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. Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. We anticipate that our pricing file updates will be completed no later than February 1, 2021. Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. 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. 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). Approval of a PAR does not guarantee payment. 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. Prescription cough and cold products may be approved with prior authorization for an acute condition for Dual Eligible (Medicare-Medicaid) members. Required for the partial fill or the completion fill of a prescription. Representation by an attorney is usually required at administrative hearings. 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 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.) Pharmacies may call the Pharmacy Support Center to request a quantity limit override 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. 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. hb```+@(1Q(b!V R;Wyjn~u~kw~}CI @B 8F8CEVR,r@Zk0226H;)maVf\p@j053s0OIk5v X u cs. Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. B. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. Required when there is payment from another source. 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. Effective 10/22/2021, Updated policy for Quantity Limit overrides in COVID-19 section. Amount expressed in metric decimal units of the product included in the compound. Required if Previous Date Of Fill (530-FU) is used. 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. 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. Required when the patient's financial responsibility is due to the coverage gap. 03 =Amount Attributed to Sales Tax (523-FN) COVID-19 medications that were procured by the federal government are free of cost to pharmacy providers. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Imp Guide: Required, if known, when patient has Medicaid coverage. Required when needed per trading partner agreement. 05 = Amount of Co-pay (518-FI) 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. Some claim submission requirements include timely filing, eligibility requirements, pursuit of third-party resources, and required attachments included. 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 reviews the claim and immediately returns a status of paid or denied for each transaction to the provider's personal computer. Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. An emergency is any condition that is life-threatening or requires immediate medical intervention. 1 = Proof of eligibility unknown or unavailable. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Payer Issued, One transaction for B2 or compound claim, Four allowed for B1 or B3, Code qualifying the 'Service Provider ID' (Field # 201-B1), This will be provided by the provider's software vendor, Assigned when vendor is certified with Magellan Rx Management - If not number is supplied, populate with zeros, UNITED STATES AND CANADIAN PROVINCE POSTAL SERVICE. Reversal Window (If transaction is billed today, what is the, Required when needed to match the reversal to the original billing transaction. 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. The table below 0 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. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. Required for partial fills. If the reconsideration is denied, the final option is to appeal the reconsideration. For DAW 8-generic not available in marketplace or DAW 9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual", Allowed by Prescriber but Plan Requests Brand. The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 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. 639 0 obj <> endobj Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. : Illustration of Cost Reimbursable Basis of Payment Types and their Components 4.1.3.1 COST REIMBURSABLE WITH NO FEE Definition This basis of payment provides only for the reimbursement to the contractor of actual costs incurred.. : Illustration of Cost Reimbursable Basis of Payment Types and their Components 4.1.3.1 COST REIMBURSABLE WITH NO FEE Definition This basis of payment provides only for the reimbursement to the contractor of actual costs incurred.. 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. BNR=Brand Name Required), claim will pay with DAW9. 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. Required when Preferred Product ID (553-AR) is used. Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. 523-FN Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). "P" indicates the quantity dispensed is a partial fill. Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). 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. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. 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 value of '05' (Acquisition) or '08' (340B Disproportionate Share Pricing/Public Health Service) in the Basis of Cost Determination field (NCPDP Field # 423-DN). Exceptions are granted only when the pharmacy is able to document that appropriate action was taken to meet filing requirements and that the pharmacy was prevented from filing as the result of extenuating unforeseen and uncontrollable circumstances. 0 WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. Required for partial fills. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. 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. 07 = Amount of Co-insurance (572-4U) iT|'r4O!JtN!EIVJB yv7kAY:@>1erpFBkz.cDEXPTo|G|r>OkWI/"j1;gT* :k $O{ftLZ>T7h.6k>a'vh?a!>7 s Required when Benefit Stage Amount (394-MW) is used. Claims that cannot be submitted through the vendor must be submitted on paper. Instructions on how to complete the PCF are available in this manual. 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. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. Enter the ingredient drug cost for each product used in making the compound. Providers must submit accurate information. 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). Sent when claim adjudication outcome requires subsequent PA number for payment. The "***" indicates that the field is repeating. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Prior authorization requests for some products may be approved based on medical necessity. Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate Program. %%EOF '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits, 3 = Other Coverage Billed Claim not Covered. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT. Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. The situations designated have qualifications for usage ("Required if x", "Not required if y"). Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. 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. NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. 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 Required if any other payment fields sent by the sender. Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) When timely filing expires due to delays in receiving third-party payment or denial documentation, the pharmacy benefit manager is authorized to consider the claim as timely if received within 60 days from the date of the third-party payment or denial or within 365 days of the date of service, whichever occurs first. 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. Required when Other Amount Claimed Submitted (480-H9) is used. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. The following lists the segments and fields in a Claim Billing or Claim Rebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Required if Other Payer Reject Code (472-6E) is used. A PAR is only necessary if an ingredient in the compound is subject to prior authorization.

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