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. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. 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. Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. Caremark Members within this eligibility category are only eligible to receive family planning and family planning-related medication. 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. Required only for secondary, tertiary, etc., claims. Medication Requiring PAR - Update to Over-the-counter products. CMS began releasing RVU information in December 2020. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT, Required for all COB claims with Other Coverage Code of 2 or 4. Prior Authorization Request (PAR) Process, Guidelines Used by the Department for Determining PAR Criteria, Incremental Fills and/or Prescription Splitting, Lost/Stolen/Damaged/Vacation Prescriptions, Temporary COVID-19 Policy and Billing Changes, Medication Prior Authorization Deferments, EUA COVID-19 Antivirals Claim Requirements, Ordering, Prescribing or Referring (OPR) Providers, Delayed Notification to the Pharmacy of Eligibility, Instructions for Completing the Pharmacy Claim Form, Response Claim Billing/Claim Rebill Payer Sheet Template, Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response, Claim Billing/Claim Rebill PAID (or Duplicate of PAID) Response, Claim Billing/Claim Rebill Accepted/Rejected Response, Claim Billing/Claim Rebill Rejected/Rejected Response, NCPDP Version D.0 Claim Reversal Template, Request Claim Reversal Payer Sheet Template, Response Claim Reversal Payer Sheet Template, Claim Reversal Accepted/Approved Response, Claim Reversal Accepted/Rejected Response, Claim Reversal Rejected/Rejected Response, Pharmacy Prior Authorization Policies section. BASIS OF CALCULATION - PERCENTAGE SALES TAX. 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. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. 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. A 7.5 percent tolerance is allowed between fills for Synagis. Reimbursement Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. 19 Antivirals Dispensing and Reimbursement Required when additional text is needed for clarification or detail. Required for the partial fill or the completion fill of a prescription. Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Required when needed to provide a support telephone number of the other payer to the receiver. Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. Required when its value has an effect on the Gross Amount Due (430-DU) calculation. Reimbursement Rates for 2021 Procedure Codes 0 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. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). Enter the ingredient drug cost for each product used in making the compound. 340B Information Exchange Reference Guide - NCPDP 81J _FLy4AyGP(O 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 form is one-sided and requires an authorized signature. 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. Providers must follow the instructions below and may only submit one (prescription) per claim. The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Electronic claim submissions must meet timely filing requirements. 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. endstream endobj startxref Appeals may be sent to: With few exceptions, providers are required to submit claims electronically. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand non-preferred formulary product. Required when Compound Ingredient Modifier Code (363-2H) is sent. The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. Required when the patient's financial responsibility is due to the coverage gap. Members of these eligibility categories will be subject to utilization management policies as outlined in the Appendix P, PDL or Appendix Y. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. ), SMAC, WAC, or AAC. Required when Basis of Reimbursement Determination (522-FM) is "14" (Patient Responsibility Amount) or "15" (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. If the medication has been determined to be family planning or family planning- related, it should be documented in the prescription record. Required when Flat Sales Tax Amount Submitted (481-HA) is greater than zero (0) or when Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement. Reimbursement Rates for 2021 Procedure Codes Required when necessary for plan benefit administration. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). A PAR approval does not override any of the claim submission requirements. Required if text is needed for clarification or detail. 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. Please contact the Pharmacy Support Center with questions. RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET This letter identifies the member's appeal rights. Reimbursable Basis Definition 1750 0 obj <>stream Required if Quantity of Previous Fill (531-FV) is used. Express Scripts 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. 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. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. 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. Required - If claim is for a compound prescription, enter "0. 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). 0 ", 00 = If claim is a multi-ingredient compound transaction, Required - If claim is for a compound prescription, enter "00.". Instructions on how to complete the PCF are available in this manual. Required when Basis of Cost Determination (432-DN) is submitted on billing. Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. 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. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Required if needed to match the reversal to the original billing transaction. 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. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Prescription cough and cold products may be approved with prior authorization for an acute condition for Dual Eligible (Medicare-Medicaid) members. 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 Pharmacies should retrieve their Remittance Advice (RA) or X12N 835 through the Provider Web Portal. Required if Patient Pay Amount (505-F5) includes deductible. 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. Pharmacies should continue to rebill until a final resolution has been reached. The following NCPDP fields below will be required on 340B transactions. Required when there is payment from another source. Companion Document To Supplement The NCPDP VERSION Signature requirements are temporarily waived for Member Counseling and Proof of Delivery. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. Testing Procedures - Alabama Medicaid Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate Program. Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. Required if Help Desk Phone Number (550-8F) is used. Required for 340B Claims. Parenteral Nutrition Products Required if the identification to be used in future transactions is different than what was submitted on the request. Coordination of Benefits/Other Payments Count, Required if Other Payer ID (Field # 340-7C) is used, Required if identification of the Other Payer Date is necessary for claim/encounter adjudication, CCYYMMDD. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Generic Drug Not in Stock, 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. 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. Required if this field could result in contractually agreed upon payment. Required for partial fills. Required when additional text is needed for clarification or detail. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. Timely filing for electronic and paper claim submission is 120 days from the date of service. 19 Antivirals Dispensing and Reimbursement ), SMAC, WAC, or AAC. 639 0 obj <> endobj AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. Amount expressed in metric decimal units of the product included in the compound. 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 OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT. Providers must submit accurate information. The total service area consists of all properties that are specifically and specially benefited. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).
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