Copies of all forms necessary for submitting claims are also available on the Pharmacy Resources web page of the Department's website. Interactive claim submission must comply with Colorado D.0 Requirements. B. If no number is supplied, populate with zeros, Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs), OCC codes 0, 1, 2, 3, and 4 Supported (no co-pay only billing allowed), COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT. 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. Pharmacies may use the number 8 in Field # 420-DK instead of obtaining a PA for non-covered ingredients to allow the claim to pay for the ingredients that are considered a covered benefit. Drugs administered in a dialysis unit are part of the dialysis fee or billed on a professional claim. The offer to counsel shall be face-to-face communication whenever practical or by telephone. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. A 7.5 percent tolerance is allowed between fills for Synagis. All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. 1 = Proof of eligibility unknown or unavailable. 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. Pharmacy employee negligence, employer failure to provide sufficient, well-trained employees, or failure to properly monitor the activities of employees and agents (e.g., billing services) are not considered extenuating circumstances beyond the pharmacy provider's control. ADDITIONAL MESSAGE INFORMATION CONTINUITY. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. This dollar amount will be provided, when known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount. 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. WebExamples of Reimbursable Basis in a sentence. If a member has Medicaid as their secondary insurance and their primary insurance covers a medication, but Health First Colorado requires a prior authorization for the medication, the pharmacy or provider may request a prior authorization override by contacting the Magellan Helpdesk at 1-800-424-5725. Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim. Required for partial fills. The table below PARs are reviewed by the Department or the pharmacy benefit manager. Required when Other Amount Claimed Submitted (480-H9) is used. Required if Other Payer Amount Paid (431-Dv) is used. Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). WebExamples of Reimbursable Basis in a sentence. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Product may require PAR based on brand-name coverage. "P" indicates the quantity dispensed is a partial fill. Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET 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. Applicable co-pay is automatically deducted from the provider's payment during claims processing. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. Required for 340B Claims. Prescription cough and cold products may be approved with prior authorization for an acute condition for Dual Eligible (Medicare-Medicaid) members. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. Sent when Other Health Insurance (OHI) is encountered during claim processing. In no case, shall prescriptions be kept in will-call status for more than 14 days. Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Effective 10/22/2021, Corrected formatting error; replaced "" with numeric "0", Added Real Time Prior Authorization via EHR to PAR Process, Updated to reflect billing changes to family planning and family planning-related services, Updated family planning-related section for clarity, Added primary insurance clarification to PAR Process and max day supply clarification to Dispensing Requirements, Added record maintenance requirements under Counseling, Retention of Records, and Signature Requirements, Removed requirement for providers to obtain a new override each fill for TPL/COB prior authorizations, Updated qualifier codes accepted in COB/ Other Payments under Claim Billing, Proposed rendering provider (if identified on the PAR), Non-preferred agents subject to the Preferred Drug List (PDL), Preferred agents with clinical criteria attached to the medication and all non-preferred agents subject to the Preferred Drug List (PDL) Over-the-counter (OTC) drugs that are not a regular Health First Colorado program benefit, Intravenous (IV) solutions with clinical criteria attached to the medication, Total Parenteral Nutrition (TPN) therapy and drugs, Significance of impact on the health of the Health First Colorado program population, Required monitoring of prescribing protocols to protect both the long-term efficacy of the drug and the public health, Potential for, or a history of, drug diversion and other illegal utilization, Appearance of the Health First Colorado program usage in amounts inconsistent with non- medical assistance program usage patterns, after adjusting for population characteristics, Clinical safety and efficacy compared to other drugs in that class of medications, Availability of more cost-effective comparable alternatives, Procedures where inappropriate utilization has been reported in medical literature, Performing auditing services with constant review on drug utilization. Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). A PAR approval does not override any of the claim submission requirements. Providers should also consult the Code of Colorado Regulations (10 C.C.R. Member's 7-character Medical Assistance Program ID. Each PA may be extended one time for 90 days. An emergency is any condition that is life-threatening or requires immediate medical intervention. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility. 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. 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 Required when needed to communicate DUR information. CMS began releasing RVU information in December 2020. 1750 0 obj <>stream Reimbursable Basis Definition 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 utilization conflict is detected. If there is more than a single payer, a D.0 electronic transaction must be submitted. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). 523-FN Required for this program when the Other Coverage Code (308-C8) of "3" is used. 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. 01 = Amount applied to periodic deductible (517-FH) Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. 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. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. not used) for this payer are excluded from the template. 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. 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. Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Download Standards Membership in NCPDP is required for access to standards. 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 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.) If PAR is authorized, claim will pay with DAW1. Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. Federal regulation requires that drug manufacturers sign a national rebate agreement with the Centers for Medicare and Medicaid Services (CMS) to participate in the state Medical Assistance Program. Confirm and document in writing the disposition Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). Members of these eligibility categories will be subject to utilization management policies as outlined in the Appendix P, PDL or Appendix Y. enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. Required when any other payment fields sent by the sender. 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. Required if Ingredient Cost Paid (506-F6) is greater than zero (0). PB 18-08 340B Claim Submission Requirements and The table below Required if Basis of Cost Determination (432-DN) is submitted on billing. Health First Colorado is temporarily deferring medication prior authorization (PA) requirements for members on all medications for which there is an existing 12-month PA approval in place. Only members have the right to appeal a PAR decision. 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 Does not obligate you to see Health First Colorado members. 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. Drug list criteria designates the brand product as preferred, (i.e. The Helpdesk is available 24 hours a day, seven days a week. 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. Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill). Required on all COB claims with Other Coverage Code of 3. 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. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a non-preferred formulary product. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. Provided for informational purposes only. INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. 340B Information Exchange Reference Guide - NCPDP 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational If a member calls the call center, the member will be directed to have the pharmacy call for the override. Prior authorization requests for some products may be approved based on medical necessity. 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). Additionally, all providers entering 340B claims must be registered and active with HRSA. Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (402-D2) occur on the same day. Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. Required when needed to provide a support telephone number of the other payer to the receiver. PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER, Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) 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. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Required when Approved Message Code (548-6F) is used. A member has tried the generic equivalent but is unable to continue treatment on the generic drug and criteria is met for medication. 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. BNR=Brand Name Required), claim will pay with DAW9. : 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.. Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. 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 Delayed notification to the pharmacy of eligibility. The total service area consists of all properties that are specifically and specially benefited. Required when needed per trading partner agreement. Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. Required if other payer has approved payment for some/all of the billing. The resubmitted request must be completed in the same manner as an original reconsideration request. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. COVID-19 early refill overrides are not available for mail-order pharmacies. 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. 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 Preferred Product ID (553-AR) is used. 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. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. 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 If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. Pharmacy Required when needed to specify the reason that submission of the transaction has been delayed. 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 if needed to provide a support telephone number of the other payer to the receiver. Required for partial fills. 12 = Amount Attributed to Coverage Gap (137-UP) If the reconsideration is denied, the final option is to appeal the reconsideration. Pharmacy Medication Requiring PAR - Update to Over-the-counter products. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. %%EOF PB 18-08 340B Claim Submission Requirements and Required when needed for receiver claim determination when multiple products are billed. 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 Members in this eligibility category may receive up to a 12-month supply ofcontraceptiveswith a $0 co-pay. Required if this field could result in contractually agreed upon payment. 1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads.
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