Amount expressed in metric decimal units of the product included in the compound. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill). It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. Metric decimal quantity of medication that would be dispensed for a full quantity. INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT. hb```+@(1Q(b!V R;Wyjn~u~kw~}CI @B 8F8CEVR,r@Zk0226H;)maVf\p@j053s0OIk5v X u cs. Required if needed by receiver to match the claim that is being reversed. A generic drug is not therapeutically equivalent to the brand name drug. 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. If the original fills for these claims have no authorized refills a new RX number is required. Health First Colorado is the payer of last resort. Representation by an attorney is usually required at administrative hearings. Instructions on how to complete the PCF are available in this manual. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). 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.) Reversal Window (If transaction is billed today, what is the, Required when needed to match the reversal to the original billing transaction. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). BASIS A PAR approval does not override any of the claim submission requirements. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Required when Basis of Cost Determination (432-DN) is submitted on billing. The "Dispense as Written (DAW) Override Codes" table describes the valid scenarios allowable per DAW code. 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. Reimbursement Required if the identification to be used in future transactions is different than what was submitted on the request. Required if Basis of Cost Determination (432-DN) is submitted on billing. 340B Information Exchange Reference Guide - NCPDP WebExamples of Reimbursable Basis in a sentence. Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). Pharmacy Caremark Testing Procedures - Alabama Medicaid B. Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. The total service area consists of all properties that are specifically and specially benefited. The Health First Colorado program restricts or excludes coverage for some drug categories. The PCF should be submitted to Magellan Rx Management agent at: Below are the completion instructions for the Colorado Pharmacy Claim Form (PCF-2) for Pharmacy Providers. Physicians and other practitioners who order, prescribe or refer items or services for Health First Colorado members, but who choose not to submit claims to Health First Colorado, are referred to as OPR providers. If there is more than a single payer, a D.0 electronic transaction must be submitted. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION. 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. Prior authorization requests for some products may be approved based on medical necessity. The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. 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. Providers must follow the instructions below and may only submit one (prescription) per claim. Drug used for erectile or sexual dysfunction. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. 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. 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 A pharmacist or pharmacist designee shall offer counseling regarding the drug therapy to each Health First Colorado member with a new or refill prescription if the pharmacist or pharmacist designee believes that it is in the best interest of the member. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. Express Scripts 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. BNR=Brand Name Required), claim will pay with DAW9. Required for 340B Claims. Required if other payer has approved payment for some/all of the billing. Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. Caremark All products in this category are regular Medical Assistance Program benefits. ), SMAC, WAC, or AAC. 661 0 obj <>/Filter/FlateDecode/ID[<62EB3A7657CA4643BE855C13B68E8087>]/Index[639 39]/Info 638 0 R/Length 107/Prev 799058/Root 640 0 R/Size 678/Type/XRef/W[1 3 1]>>stream SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). 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. Required when Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. Required when needed for receiver claim determination when multiple products are billed. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. Required when the patient's financial responsibility is due to the coverage gap. 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 if Basis of Cost Determination (432-DN) is submitted on billing. Required if this field could result in contractually agreed upon 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. Electronic claim submissions must meet timely filing requirements. If the reconsideration is denied, the final option is to appeal the reconsideration. 01 = Amount applied to periodic deductible (517-FH) 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. "P" indicates the quantity dispensed is a partial fill. Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational 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 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. PB 18-08 340B Claim Submission Requirements and Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. Required only for secondary, tertiary, etc., claims. Required for partial fills. Sent when claim adjudication outcome requires subsequent PA number for payment. Required when this value is used to arrive at the final reimbursement. All necessary forms should be submitted to Magellan Rx Management at: There are four exceptions to the 120-day rule: Each of these exceptions is detailed below along with the specific instructions for submitting claims. Required if Previous Date of Fill (530-FU) is used. The claim may be a multi-line compound claim. 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. Reimbursement "Required When." 523-FN Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. Required when necessary for plan benefit administration. In determining what drugs should be subject to prior authorization, the following criteria is used: Most brand-name drugs with a generic therapeutic equivalent are not covered by the Health First Colorado program. 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. More information may be obtained in Appendix P in the Billing Manuals section of the Department's website. Dispensing (Incentive) Fee = Standard dispense fee based on a pharmacys total annual prescription volume will still apply. A PAR is only necessary if an ingredient in the compound is subject to prior authorization. The standard drug ingredient reimbursement methodology applies to the quantity dispensed with each fill. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Each PA may be extended one time for 90 days. Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT. 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. If the medication has been determined to be family planning or family planning-related, it should be documented in the prescription record. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). 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 Payer Specifications D.0 B. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. 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 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. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL EY 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. 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. Reimbursement Basis Definition For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Required when needed to provide a support telephone number of the other payer to the receiver. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. 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 following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER, ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. 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. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. COMPOUND INGREDIENT BASIS OF COST DETERMINATION. The use of inaccurate or false information can result in the reversal of claims. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). Confirm and document in writing the disposition Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. PB 18-08 340B Claim Submission Requirements and 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. Required when necessary to identify the Patient's portion of the Sales Tax. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). In addition, some products are excluded from coverage and are listed in the Restricted Products section. Required when a product preference exists that needs to be communicated to the receiver via an ID. Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. Confirm and document in writing the disposition Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. iT|'r4O!JtN!EIVJB yv7kAY:@>1erpFBkz.cDEXPTo|G|r>OkWI/"j1;gT* :k $O{ftLZ>T7h.6k>a'vh?a!>7 s Required when needed to identify the transaction. Required for partial fills. 340B Information Exchange Reference Guide - NCPDP The situations designated have qualifications for usage ("Required if x", "Not required if 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. Reimbursable Basis Definition Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. The resubmitted request must be completed in the same manner as an original reconsideration request. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). 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. Date of service for the Associated Prescription/Service Reference Number (456-EN). Delayed notification to the pharmacy of eligibility. The total service area consists of all properties that are specifically and specially benefited. 03 =Amount Attributed to Sales Tax (523-FN) Incremental and subsequent fills may not be transferred from one pharmacy to another. 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. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational %PDF-1.5 % The Health First Colorado program does not pay a compounding fee. The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. not used) for this payer are excluded from the template. Enrolled Medicaid fee-for-service (FFS) members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies. Required for partial fills. Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Member's 7-character Medical Assistance Program ID. The table below Required when Previous Date Of Fill (530-FU) is used. 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.

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