1710 0 obj <> endobj Drugs administered in clinics, these must be billed by the clinic on a professional claim. Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER, ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. The following NCPDP fields below will be required on 340B transactions. Required when needed to specify the reason that submission of the transaction has been delayed. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. An emergency is any condition that is life-threatening or requires immediate medical intervention. If the reconsideration is denied, the final option is to appeal the reconsideration. The claim may be a multi-line compound claim. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. Applicable co-pay is automatically deducted from the provider's payment during claims processing. Required if Other Payer Amount Paid (431-Dv) is used. Testing Procedures - Alabama Medicaid Required if Previous Date of Fill (530-FU) is used. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. Health First Colorado is the payer of last resort. 04 = Amount Exceeding Periodic Benefit Maximum (520-FK) OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT, Required for all COB claims with Other Coverage Code of 2 or 4. Required when Basis of Cost Determination (432-DN) is submitted on billing. 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. Services cannot be withheld if the member is unable to pay the co-pay. Required if Approved Message Code (548-6F) is used. Required if needed to supply additional information for the utilization conflict. Required when Quantity of Previous Fill (531-FV) is used. 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). WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately. 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. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. It is used for multi-ingredient prescriptions, when each ingredient is reported. Electronic claim submissions must meet timely filing requirements. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. 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. 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. Access to Standards 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. WebExamples of Reimbursable Basis in a sentence. Member Contact Center1-800-221-3943/State Relay: 711. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. Required if the identification to be used in future transactions is different than what was submitted on the request. Providers should also consult the Code of Colorado Regulations (10 C.C.R. 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. not used) for this payer are excluded from the template. Cheratussin AC, Virtussin AC). %%EOF Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Reimbursement The number of authorized refills must be consistent with the original paid claim for all subsequent refills. The use of inaccurate or false information can result in the reversal of claims. 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. Parenteral Nutrition Products Required if this field could result in contractually agreed upon payment. Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. Indicates that the drug was purchased through the 340B Drug Pricing Program. 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. 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. For more information related to physician administered drugs and billing for this population, please visit the Physician-Administered-Drug (PAD) Billing Manual. 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. B. Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQW) follows it, and the text of the following message is a continuation of the current. Prescription cough and cold products may be approved with prior authorization for an acute condition for Dual Eligible (Medicare-Medicaid) members. Required for 340B Claims. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. 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 Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). 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. Required if Other Amount Claimed Submitted (480-H9) is greater than zero (0). Required when Basis of Cost Determination (432-DN) is submitted on billing. 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. A PAR approval does not override any of the claim submission requirements. Required on all COB claims with Other Coverage Code of 3. 677 0 obj <>stream Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. ", 00 = If claim is a multi-ingredient compound transaction, Required - If claim is for a compound prescription, enter "00.". Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. The Health First Colorado program restricts or excludes coverage for some drug categories. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). BNR=Brand Name Required), claim will pay with DAW9. Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). 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)). Required when this value is used to arrive at the final reimbursement. Prescription cough and cold products for all ages will not require prior authorization for Health First Colorado members. 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 Basis of Cost Determination (432-DN) is submitted on billing. Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program. Reimbursable Basis Definition Required - Enter total ingredient costs even if claim is for a compound prescription. Figure 4.1.3.a. Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website. Required only when 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. Required if necessary as component of Gross Amount Due. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). 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. Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. Required when any other payment fields sent by the sender. All products in this category are regular Medical Assistance Program benefits. If PAR is authorized, claim will pay with DAW1. 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) 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. If the appropriate numbers of days have not lapsed, the claim will be denied as a refill-too-soon unless there has been a change in the dosing. Pharmacies may submit claims electronically by obtaining a PAR from thePharmacy Support Center. Reimbursable Basis Definition The Department does not pay for early refills when needed for a vacation supply. 06 = Patient Pay Amount (505-F5) 639 0 obj <> endobj The provider creates interactive claims one at a time and transmits them by toll-free telephone through a switch company to the pharmacy benefit manager. 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 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. Required if needed to identify the transaction. A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. 19 Antivirals Dispensing and Reimbursement 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 when needed to supply additional information for the utilization conflict. Only members have the right to appeal a PAR decision. Required when text is needed for clarification or detail. Required when Basis of Cost Determination (432-DN) is submitted on billing. 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. Single agent antihistamines and their combination products with a decongestant are not considered to be cough and cold products and are regular Medical Assistance Program benefits. 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. 03 =Amount Attributed to Sales Tax (523-FN) The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. Required if any other payment fields sent by the sender. Members that meet their monthly co-pay maximum, or 5% of their monthly household income, will be exempt from co-pay for the remainder of that month. Required when Submission Clarification Code (420-DK) is used. 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. Provided for informational purposes only. 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. Confirm and document in writing the disposition Required when necessary to identify the Patient's portion of the Sales Tax. Billing Guidance for Pharmacists Professional and RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility. 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 when Other Payer ID (340-7C) is used. Required when Other Amount Claimed Submitted (480-H9) is used. SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). 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. This letter identifies the member's appeal rights. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. Express Scripts 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. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. Dispensing (Incentive) Fee = Standard dispense fee based on a pharmacys total annual prescription volume will still apply. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. 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. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required.". For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Brand Drug Dispensed as a Generic, Substitution Not Allowed - Brand Drug Mandated by Law, Substitution Allowed - Generic Drug Not Available in Marketplace. The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. 523-FN Prescriptions generally cannot be dispensed in quantities less than the physician ordered unless the quantity ordered is more than a 100-day supply for maintenance medications or more than a 30-day supply for non-maintenance medications. ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. hbbd```b``"`DrVH$0"":``9@n]bLlv #3~ ` +c 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. 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 1 = Proof of eligibility unknown or unavailable. Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. 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.
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basis of reimbursement determination codes 2023