Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. WebBASIS OF REIMBURSEMENT DETERMINATION: 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. Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. Express Scripts 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 Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Required for this program when the Other Coverage Code (308-C8) of "3" is used. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional If a member calls the call center, the member will be directed to have the pharmacy call for the override. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORMULARY SELECTION. Pharmacies may submit claims electronically by obtaining a PAR from thePharmacy Support Center. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. 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. Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Required when needed per trading partner agreement. Pharmacies may electronically rebill denied claims when the claim submission is within 120 days of the date of service. Signature requirements are temporarily waived for Member Counseling and Proof of Delivery. The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication. 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 Required when Other Amount Claimed Submitted (480-H9) is used. hbbd```b``} DL`D^A$KT`H2nfA H/# -~$G@3@"@*Z? 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. One of the other designators, "M", "R" or "RW" will precede it. Does not obligate you to see Health First Colorado members. The procedure to request a PAR and the medications that require a PAR are outlined in Appendix P - Pharmacy Benefit Prior Authorization Procedures and Criterialocated in the Pharmacy Prior Authorization Policies section of the Department's website. Maternal, Child and Reproductive Health billing manual web page. ), SMAC, WAC, or AAC. iT|'r4O!JtN!EIVJB yv7kAY:@>1erpFBkz.cDEXPTo|G|r>OkWI/"j1;gT* :k $O{ftLZ>T7h.6k>a'vh?a!>7 s PB 18-08 340B Claim Submission Requirements and WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. 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. Mental illness as defined in C.R.S 10-16-104 (5.5). 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. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER, ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Required if Patient Pay Amount (505-F5) includes co-pay as patient financial responsibility. Required for the partial fill or the completion fill of a prescription. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. * Cough and cold products: Cough and cold products include combinations of narcotic and nonnarcotic cough suppressants, expectorants, and/or decongestants. The situations designated have qualifications for usage ("Required if x", "Not required if y"). 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 when other coverage is known, which is after the Date of Service submitted. 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. Required when Other Payer ID (340-7C) is used. RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET Reimbursement Basis Definition Required when Additional Message Information (526-FQ) is used. All products in this category are regular Medical Assistance Program benefits. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). A compounded prescription (a prescription where two or more ingredients are combined to achieve a desired therapeutic effect) must be submitted on the same claim. The following claims can be submitted on paper and processed for payment: Providers can submit only one claim per submission on the PCF, however, compound claims can be submitted. Payer Specifications D.0 endstream endobj startxref Required if other payer has approved payment for some/all of the billing. WebExamples of Reimbursable Basis in a sentence. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. Durable Medical Equipment (DME), these must be billed as a medical benefit on a professional claim. 03 = National Drug Code (NDC) - Formatted 11 digits (N). Required if needed to supply additional information for the utilization conflict. Medication Requiring PAR - Update to Over-the-counter products. 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 WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). 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. The following categories of members are exempt from co-pay: Effective July 1, 2022, the following changes occurred as it relates to family planning and family planning-related pharmacy benefits. Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. Provided for informational purposes only. 13 = Amount Attributed to Processor Fee (571-NZ). Required when necessary to identify the Plan's portion of the Sales Tax. Download Standards Membership in NCPDP is required for access to standards. 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 if Other Amount Claimed Submitted (480-H9) is greater than zero (0). Caremark The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. If the claim is denied, pharmacy benefit manager will send one or more denial reason(s) that identify the problem(s). Required when Basis of Cost Determination (432-DN) is submitted on billing. 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. Required - If claim is for a compound prescription, list total # of units for claim. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. Required if Additional Message Information (526-FQ) is used. Only members have the right to appeal a PAR decision. Required if needed to match the reversal to the original billing transaction. This document contains the specifications of six templates: Payer: Please list each transaction supported with the segments, fields and pertinent information on each transaction. 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 WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. 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. Each PA may be extended one time for 90 days. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. 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. RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. 523-FN Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed. Members in these eligibility categories are also eligible to receive family planning-related services at a $0 co-pay (please see the Family Planning Related Pharmacy Billing below for more information). Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. Required - If claim is for a compound prescription, enter "0. The "***" indicates that the field is repeating. Pharmacy Cheratussin AC, Virtussin AC). Required if this value is used to arrive at the final reimbursement. Metric decimal quantity of medication that would be dispensed for a full quantity. Testing Procedures - Alabama Medicaid 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational 0 Required if Incentive Amount Submitted (438-E3) is greater than zero (0).