Required when any other payment fields sent by the sender. ", 00 = If claim is a multi-ingredient compound transaction, Required - If claim is for a compound prescription, enter "00.". Figure 4.1.3.a. Values other than 0, 1, 08 and 09 will deny. %%EOF RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Providers must submit accurate information. Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. If reversal is for multi-ingredient prescription, the value must be 00. Required when a product preference exists that needs to be communicated to the receiver via an ID. New PAs and existing PA approvals that are less than 12 months are not eligible for deferment. The total service area consists of all properties that are specifically and specially benefited. 1 = Proof of eligibility unknown or unavailable. A generic drug is not therapeutically equivalent to the brand name drug. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Required when Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. endstream endobj startxref Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. It is used when a sender notifies the receiver of drug utilization, drug evaluations, or information on the appropriate selection to process the claim/encounter. 05 = Amount of Co-pay (518-FI) Members within this eligibility category are only eligible to receive family planning and family planning-related medication. Required when Basis of Cost Determination (432-DN) is submitted on billing. Required when the patient's financial responsibility is due to the coverage gap. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. Please visit the OPR section of the Department's website for more detailed information about enrollment and compliance with the Affordable Care Act. hb```+@(1Q(b!V R;Wyjn~u~kw~}CI @B 8F8CEVR,r@Zk0226H;)maVf\p@j053s0OIk5v X u cs. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. Services cannot be withheld if the member is unable to pay the co-pay. 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. 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. 340B Information Exchange Reference Guide - NCPDP Caremark Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. DESI drugs and any drug if by its generic makeup and route of administration, it is identical, related, or similar to a less than effective drug identified by the FDA, Drugs classified by the U.S.D.H.H.S. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. If the original fills for these claims have no authorized refills a new RX number is required. Pharmacies are expected to keep records indicating when member counseling was not or could not be provided. Pharmacies may electronically rebill denied claims when the claim submission is within 120 days of the date of service. 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 Required if Other Payer Amount Paid Qualifier (342-HC) is used. 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. 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 Figure 4.1.3.a. Health First Colorado does not provide reimbursement for products by manufacturers that have not signed a rebate agreement unless the Department has made a determination that the availability of the drug is essential, such drug has been given 1-A rating by the Food and Drug Administration (FDA), and prior authorized. Required if Patient Pay Amount (505-F5) includes deductible. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. 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. ADDITIONAL MESSAGE INFORMATION CONTINUITY. Required when other insurance information is available for coordination of benefits. 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 when there is payment from another source. 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 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. Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. OTHER PAYER - PATIENT RESPONSIBILITY AMOUNT COUNT, Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used, OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFER, Required if Other Payer-Patient Responsibility Amount (352-NQ) is used352-NQ. Requests for Reconsideration must be filed in writing with the pharmacy benefit manager within 60 days of the most recent claim or prior reconsideration denial. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. Required when Benefit Stage Amount (394-MW) is used. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. Each PA may be extended one time for 90 days. The maternity cycle is the time period during the pregnancy and 365days' post-partum. Prior authorization requests for some products may be approved based on medical necessity. 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. '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits, 3 = Other Coverage Billed Claim not Covered. 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. ), SMAC, WAC, or AAC. 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. Confirm and document in writing the disposition Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. Required for this program when the Other Coverage Code (308-C8) of "3" is used. 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. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER. EY Required when a product preference exists that either cannot be communicated by the Preferred Product ID (553-AR) or to clarify the Preferred Product ID (553-AR). Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Sent when DUR intervention is encountered during claim processing. Required on all COB claims with Other Coverage Code of 3, OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT, Required on all COB claims with Other Coverage Code of 2 or 4, OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER. Expanded Income and Title XIX (Fee-For-Service): Members with incomes up to 260% of the federal poverty level (expanded income) and in the Title XIX (Fee-For-Service) eligibility categories may receive up to a 12- month supply of contraceptives with a $0 co-pay. Required when Patient Pay Amount (505-F5) includes deductible. Reimbursable Basis Definition 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. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. In addition, some products are excluded from coverage and are listed in the Restricted Products section. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). 1750 0 obj <>stream 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. Reimbursement Required if needed by receiver to match the claim that is being reversed. 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. 0 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. Required if this value is used to arrive at the final reimbursement. 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. Testing Procedures - Alabama Medicaid Members who were formerly in foster care are co-pay exempt until their 26th birthday, Services provided by Community Mental Health Services, Members receiving a prescription for Tobacco Cessation Product. Required when Basis of Cost Determination (432-DN) is submitted on billing. Required when Other Amount Paid (565-J4) is used. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER. Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program. The table below Required when a repeating field is in error, to identify repeating field occurrence. Indicates that the drug was purchased through the 340B Drug Pricing Program. The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required if Other Payer Amount Paid (431-Dv) is used. It is used for multi-ingredient prescriptions, when each ingredient is reported. Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. The use of inaccurate or false information can result in the reversal of claims. If PAR is authorized, claim will pay with DAW1. 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. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. 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. Signature requirements are temporarily waived for Member Counseling and Proof of Delivery. Figure 4.1.3.a. Cost-sharing for members must not exceed 5% of their monthly household income. 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 Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. not used) for this payer are excluded from the template. Required when the Other Payer Reject Code (472-6E) is used. Required if Basis of Cost Determination (432-DN) is submitted on billing. 03 = National Drug Code (NDC) - Formatted 11 digits (N). The total service area consists of all properties that are specifically and specially benefited. Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed. 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.) Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. IV equipment (for example, Venopaks dispensed without the IV solutions). 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. Required when necessary to identify the Patient's portion of the Sales Tax. Sent when Other Health Insurance (OHI) is encountered during claims processing. 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. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) 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. 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. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. "P" indicates the quantity dispensed is a partial fill. 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. 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. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. Note: the pharmacy may call the Pharmacy Support Center to request a zero co-pay 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. 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 Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand non-preferred formulary product.
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