It will contain an estimate of the difference between the cost of the brand drug and the generic drug, when the brand drug is more expensive than the generic. Reimbursable Basis Definition 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 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. Testing Procedures - Alabama Medicaid Required when Help Desk Phone Number (550-8F) is used. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. BNR=Brand Name Required), claim will pay with DAW9. Durable Medical Equipment (DME), these must be billed as a medical benefit on a professional claim. Representation by an attorney is usually required at administrative hearings. If a pharmacy disagrees with the final decision of the pharmacy benefit manager, the pharmacy may file an appeal with the Office of Administrative Courts. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Payer Specifications D.0 522-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 The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. The Helpdesk is available 24 hours a day, seven days a week. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Required if necessary as component of Gross Amount Due. Providers must submit accurate information. "Required When." For the expanded income group, if the prescriber confirms that the drug was not prescribed in relation to a family planning visit, then it will be denied. 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. %%EOF %PDF-1.5 % Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. "P" indicates the quantity dispensed is a partial fill. Only members have the right to appeal a PAR decision. 03 = National Drug Code (NDC) - Formatted 11 digits (N). 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 Timely filing for electronic and paper claim submission is 120 days from the date of service. Required on all COB claims with Other Coverage Code of 3. Required when Quantity of Previous Fill (531-FV) is used. COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT, 03 = Bank Information Number (BIN) Card Issuer ID. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. Reimbursable Basis Definition Required for this program when the Other Coverage Code (308-C8) of "3" is used. Required when necessary to identify the Plan's portion of the Sales Tax. Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION. All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. A 7.5 percent tolerance is allowed between fills for Synagis. 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. New PAs and existing PA approvals that are less than 12 months are not eligible for deferment. Does not mean you will be listed as a Health First Colorado provider for patient assignment or referral, Allows you to continue to see Health First Colorado members without billing Health First Colorado, and. Pharmacies are expected to keep records indicating when member counseling was not or could not be provided. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Maternal, Child and Reproductive Health billing manual web page. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. 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 The maternity cycle is the time period during the pregnancy and 365days' post-partum. endstream endobj 1711 0 obj <>>>/Filter/Standard/Length 128/O(V^TpFH<1b,pdk%{ \rL)/P -1052/R 4/StmF/StdCF/StrF/StdCF/U(Z6r>H8 )/V 4>> endobj 1712 0 obj <>/Metadata 104 0 R/Outlines 447 0 R/PageLayout/OneColumn/Pages 1702 0 R/StructTreeRoot 608 0 R/Type/Catalog>> endobj 1713 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1714 0 obj <>stream Each PA may be extended one time for 90 days. 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. Parenteral Nutrition Products WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. 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. Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. 1 = Proof of eligibility unknown or unavailable. Required when its value has an effect on the Gross Amount Due (430-DU) calculation. Non-maintenance products submitted by a pharmacy for mail-order prescriptions will deny. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. Required if Reason for Service Code (439-E4) is used. Required for 340B Claims. Some claim submission requirements include timely filing, eligibility requirements, pursuit of third-party resources, and required attachments included. Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. If reversal is for multi-ingredient prescription, the value must be 00. Required when any other payment fields sent by the sender. Members within this eligibility category are only eligible to receive family planning and family planning-related medication. Download Standards Membership in NCPDP is required for access to standards. If the medication has been determined to be family planning or family planning-related, it should be documented in the prescription record. * Cough and cold products: Cough and cold products include combinations of narcotic and nonnarcotic cough suppressants, expectorants, and/or decongestants. Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. Required - Enter total ingredient costs even if claim is for a compound prescription. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required when a repeating field is in error, to identify repeating field occurrence. 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 Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility. Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Please contact the Pharmacy Support Center with questions. 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 Parenteral Nutrition Products Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. 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 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 The field has been designated with the situation of "Required" for the Segment in the designated Transaction. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. 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. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. 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. 20 = 340B - Indicates that, prior to providing service, the pharmacy has determined the product being billed is purchased pursuant to rights available under Section 340B of the Public Health Act of 1992 including sub-ceiling purchases authorized by Section 340B (a) (10) and those made through the Prime Vendor Program (Section 340B(a)(8)). ), SMAC, WAC, or AAC. A generic drug is not therapeutically equivalent to the brand name drug. Required for the partial fill or the completion fill of a prescription. 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. WebExamples of Reimbursable Basis in a sentence. 01 = Amount applied to periodic deductible (517-FH) Required if Additional Message Information (526-FQ) is used. 677 0 obj <>stream Members in this eligibility category may receive up to a 12-month supply ofcontraceptiveswith a $0 co-pay. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax. If a member calls the call center, the member will be directed to have the pharmacy call for the override. 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. Electronic claim submissions must meet timely filing requirements. 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. 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. 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. Required if utilization conflict is detected. Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. 639 0 obj <> endobj Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. iT|'r4O!JtN!EIVJB yv7kAY:@>1erpFBkz.cDEXPTo|G|r>OkWI/"j1;gT* :k $O{ftLZ>T7h.6k>a'vh?a!>7 s =y?@d:qb@6l7YC&)H]zjse/0 m{YSqT;?z~bDG_agiZo8pomle;]Zt QmF8@bt/ &|=SM1LZTr'hxu&0\lcmUFC!BKXrT} 7IFD&t{TagKwRI>T$ wja Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Caremark WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. 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. Note: The format for entering a date is different than the date format in the POS system ***. 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. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. Confirm and document in writing the disposition Member Contact Center1-800-221-3943/State Relay: 711. Billing Guidance for Pharmacists Professional and Effective November 1, 2022, the Department is implementing a list of family planning-related drugs that may be covered pursuant to existing utilization management policies as outlined in the Appendix P, PDL or Appendix Y, if applicable. Required when needed to provide a support telephone number. 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. 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) Providers should also consult the Code of Colorado Regulations (10 C.C.R. 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. Signature requirements are temporarily waived for Member Counseling and Proof of Delivery. 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 when Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. Note: Fields that are not used in the Claim Billing/Claim Re-bill transactions and those that do not have qualified requirements (.i.e., not used) for this payer are excluded from the template. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Required when utilization conflict is detected. Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required.". Required if this field could result in contractually agreed upon payment. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT, Required for all COB claims with Other Coverage Code of 2 or 4. enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational 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. Appeals may be sent to: With few exceptions, providers are required to submit claims electronically. 06 = Patient Pay Amount (505-F5) It is used for multi-ingredient prescriptions, when each ingredient is reported. : 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.. The following lists the segments and fields in a Claim Billing or Claim Re-bill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Required when Other Amount Paid (565-J4) is used. NCPDP Telecommunication Standard Version/Release #: Provider Relations Help Desk Information: NCPDP Telecommunication version 5.1 until TBD. Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. 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. Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Required for partial fills. Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim. Express Scripts 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. Pharmacies may submit claims electronically by obtaining a PAR from thePharmacy Support Center. Member's 7-character Medical Assistance Program ID. Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill). Family planning (e.g., contraceptives) services are configured for a $0 co-pay. The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. Delayed notification to the pharmacy of eligibility. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. 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. Basis of Cost Determination = This is not a required field on the claim, but 05 (Acquisition) or 08 (340B/Disproportionate Share Pricing/Public Health Service) will be accepted if submitted on the claim. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. Providers must submit accurate information. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. 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. Health First Colorado is the payer of last resort. The physician is of an opinion that a transition to the generic equivalent of a brand-name drug would be unacceptably disruptive to the patient's stabilized drug regimen and criteria is met for medication. A pharmacy should utilize field 461-EU on a pharmacy claim to indicate 6-Family Plan to receive a $0 co-pay on family planning related medications. ADDITIONAL MESSAGE INFORMATION CONTINUITY. The form is one-sided and requires an authorized signature. Claim Billing Accepted/RejectedMaximum Count of 3 Field # 355NT 3385C3396C347C991MH 356NU992MJ142UV143UW 144UX 145UY Response Coordination of Benefits/Other Payers SegmentSegment Identification (111AM) = 28 NCPDP Field Name OTHER PAYER ID COUNT Q,iDfh|)vCDD&I}nd~S&":@*DcS|]!ph);`s/EyxS5] zVHJ~4]T}+1d'R(3sk0YwIz$[))xB:H U]yno- VN1!Q`d/%a^4\+ feCDX$t]Sd?QT"I/%. Members within this eligibility category will not be subject to utilization management policies as outlined in the Appendix P, Preferred Drug List (PDL) or Appendix Y. All products in this category are regular Medical Assistance Program benefits. Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. 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 this field is reporting a contractually agreed upon payment. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. Required if this value is used to arrive at the final reimbursement. Billing Guidance for Pharmacists Professional and 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. 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. We anticipate that our pricing file updates will be completed no later than February 1, 2021. Required for 340B Claims. Required when needed per trading partner agreement. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. 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. The total service area consists of all properties that are specifically and specially benefited. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. Required when a product preference exists that needs to be communicated to the receiver via an ID. Express Scripts Required when Benefit Stage Amount (394-MW) is used. Required for partial fills. Pharmacy The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. 523-FN 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. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. Pharmacy Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL Please refer to the specific rules and requirements regarding electronic and paper claims below. WebExamples of Reimbursable Basis in a sentence. 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 - If claim is for a compound prescription, list total # of units for claim. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes.
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