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. If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax. Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. Drugs administered in clinics, these must be billed by the clinic on a professional claim. hb```+@(1Q(b!V R;Wyjn~u~kw~}CI @B 8F8CEVR,r@Zk0226H;)maVf\p@j053s0OIk5v X u cs. SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). Required when Basis of Cost Determination (432-DN) is submitted on billing. Required if Other Payer Amount Paid Qualifier (342-HC) is used. Required if Reason for Service Code (439-E4) is used. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. 639 0 obj <> endobj 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 If the original fills for these claims have no authorized refills a new RX number is required. Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Substitution Allowed - Pharmacist Selected Product Dispensed, NCPDP 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. 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. Paper claims may be submitted using a pharmacy claim form. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. Figure 4.1.3.a. If the claim is denied, pharmacy benefit manager will send one or more denial reason(s) that identify the problem(s). 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. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. Required - Enter total ingredient costs even if claim is for a compound prescription. %PDF-1.5 % 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. For DAW 8-generic not available in marketplace or DAW 9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual", Allowed by Prescriber but Plan Requests Brand. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. 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. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER, Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Required when Other Amount Paid (565-J4) is used. Download Standards Membership in NCPDP is required for access to standards. Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. 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. Claims that cannot be submitted through the vendor must be submitted on paper. "C" indicates the completion of a partial fill. 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. 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 when the Other Payer Reject Code (472-6E) is used. Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc. Required when necessary for patient financial responsibility only billing. Provided for informational purposes only. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT. Required if Help Desk Phone Number (550-8F) is used. Required when the patient's financial responsibility is due to the coverage gap. 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. 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 additional text is needed for clarification or detail. Required when needed to communicate DUR information. Required when text is needed for clarification or detail. ), SMAC, WAC, or AAC. 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. 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. 1-5 = Refill number - Number of the replenishment, 8 = Substitution Allowed-Generic Drug Not Available in Marketplace, 1-99 = Authorized Refill number - with 99 being as needed, refills unlimited, 8 = Process Compound For Approved Ingredients. 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 For DEA Schedule 2 through 5 drugs, 85 percent of the days' supply of the last fill must lapse before a drug can be filled again. 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 claim is for a compound prescription, enter "0. Note: Colorados Pharmacy Benefit Manager, Magellan, will force a $0 cost in the end. 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. iT|'r4O!JtN!EIVJB yv7kAY:@>1erpFBkz.cDEXPTo|G|r>OkWI/"j1;gT* :k $O{ftLZ>T7h.6k>a'vh?a!>7 s Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. 1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads. Required if Previous Date of Fill (530-FU) is used. 0 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational CMS began releasing RVU information in December 2020. Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). Required if Incentive Amount Submitted (438-E3) is greater than zero (0). Required when needed for receiver claim determination when multiple products are billed. Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. 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. 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. Required when Basis of Cost Determination (432-DN) is submitted on billing. Required if the identification to be used in future transactions is different than what was submitted on the request. Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill). This requirement stems from the Social Security Act, 42 U.S.C. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. Required if Other Payer Amount Paid (431-Dv) is used. The following lists the segments and fields in a Claim Billing or Claim Rebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 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). ADDITIONAL MESSAGE INFORMATION CONTINUITY. Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. 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. The maternity cycle is the time period during the pregnancy and 365days' post-partum. Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. Mental illness as defined in C.R.S 10-16-104 (5.5). 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. 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. Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) CMS began releasing RVU information in December 2020. Required when needed to provide a support telephone number of the other payer to the receiver. 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. These values are for covered outpatient drugs. Dispensing (Incentive) Fee = Standard dispense fee based on a pharmacys total annual prescription volume will still apply. We anticipate that our pricing file updates will be completed no later than February 1, 2021. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Required if Patient Pay Amount (505-F5) includes co-pay as patient financial responsibility. ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. 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. B. enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). Enter the ingredient drug cost for each product used in making the compound. Cost-sharing for members must not exceed 5% of their monthly household income. The table below '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits, 3 = Other Coverage Billed Claim not Covered. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Required when needed to provide a support telephone number. Sent when Other Health Insurance (OHI) is encountered during claims processing. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. 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. 523-FN An emergency is any condition that is life-threatening or requires immediate medical intervention. Required for 340B Claims. Please contact the Pharmacy Support Center with questions. Required only for secondary, tertiary, etc., claims. 677 0 obj <>stream One of the other designators, "M", "R" or "RW" will precede it. Other Payer Bank Information Number (BIN). Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. 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). Required when necessary to identify the Plan's portion of the Sales Tax. 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 The Field has been designated with the situation of "Required" for the Segment in the designated Transaction.
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