512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. EY SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). Claims that do not result in the Health First Colorado program authorizing reimbursement for services rendered may be resubmitted. 1710 0 obj <> endobj WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. The total service area consists of all properties that are specifically and specially benefited. Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). 01 = Amount applied to periodic deductible (517-FH) The situations designated have qualifications for usage ("Required when x,"Not Required when y"). 523-FN Pharmacies must call for overrides for lost, stolen, or damaged prescriptions. Appeals may be sent to: With few exceptions, providers are required to submit claims electronically. 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. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. 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 Durable Medical Equipment (DME), these must be billed as a medical benefit on a professional claim. WebExamples of Reimbursable Basis in a sentence. 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. Caremark The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. Required if needed to supply additional information for the utilization conflict. Required if Previous Date of Fill (530-FU) is used. Required if Other Payer ID (340-7C) is used. Required to identify the actual group that was used when multiple group coverage exist. Members in this eligibility category may receive up to a 12-month supply ofcontraceptiveswith a $0 co-pay. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Electronic claim submissions must meet timely filing requirements. Required when needed to specify the reason that submission of the transaction has been delayed. Required when Additional Message Information (526-FQ) is used. All services to women in the maternity cycle. 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 Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET Family planning (e.g., contraceptives) services are configured for a $0 co-pay. 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. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. Required if this field could result in contractually agreed upon payment. Some claim submission requirements include timely filing, eligibility requirements, pursuit of third-party resources, and required attachments included. FDA as "investigational" or "experimental", Dietary needs or food supplements (see Appendix P for a list), Medicare Part D drugs for Part D eligible members, including compound claims that contain a drug not listed on the dual eligible drug list. Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Flat Sales Tax Amount Paid (558-AW) is greater than zero (0). Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. 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. 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. Parenteral Nutrition Products The following lists the segments and fields in a Claim Billing or Claim Re-bill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. WebExamples of Reimbursable Basis in a sentence. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Required when Compound Ingredient Modifier Code (363-2H) is sent. The following NCPDP fields below will be required on 340B transactions. Required if needed to match the reversal to the original billing transaction. Interactive claim submission must comply with Colorado D.0 Requirements. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). 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. These records must be maintained for at least seven (7) years. 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. 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. 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. 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). : Illustration of Cost Reimbursable Basis of Payment Types and their Components 4.1.3.1 COST REIMBURSABLE WITH NO FEE Definition This basis of payment provides only for the reimbursement to the contractor of actual costs incurred.. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). 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 if utilization conflict is detected. The total service area consists of all properties that are specifically and specially benefited. 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. 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. 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 not used) for this payer are excluded from the template. 19 Antivirals Dispensing and Reimbursement Required when Basis of Cost Determination (432-DN) is submitted on billing. Access to Standards 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 Metric decimal quantity of medication that would be dispensed for a full quantity. 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 for partial fills. Required for 340B Claims. The resubmitted request must be completed in the same manner as an original reconsideration request. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. 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. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. The standard drug ingredient reimbursement methodology applies to the quantity dispensed with each fill. 523-FN Drug list criteria designates the brand product as preferred, (i.e. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). 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. Each PA may be extended one time for 90 days. Required when Previous Date Of Fill (530-FU) is used. For all other information as it relates to family planning benefits, please visit the Maternal, Child and Reproductive Health billing manual web page. BASIS 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. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. =y?@d:qb@6l7YC&)H]zjse/0 m{YSqT;?z~bDG_agiZo8pomle;]Zt QmF8@bt/ &|=SM1LZTr'hxu&0\lcmUFC!BKXrT} 7IFD&t{TagKwRI>T$ wja Providers should also consult the Code of Colorado Regulations (10 C.C.R. 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. Download Standards Membership in NCPDP is required for access to standards. 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. AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. Required if Approved Message Code (548-6F) is used. B. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. Only members have the right to appeal a PAR decision. PB 18-08 340B Claim Submission Requirements and BASIS 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 any other payment fields sent by the sender. In an emergency, when a PAR cannot be obtained in time to fill the prescription, pharmacies may dispense a 72-hour supply (3 days) of covered outpatient prescription drugs to an eligible member by calling the Pharmacy Support Center. Required when Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. Required if Other Payer Amount Paid (431-Dv) is used. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. All products in this category are regular Medical Assistance Program benefits. CMS began releasing RVU information in December 2020. Reimbursement Basis Definition RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Pharmacies should retrieve their Remittance Advice (RA) or X12N 835 through the Provider Web Portal. Required when Quantity of Previous Fill (531-FV) is used. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. 81J _FLy4AyGP(O Drug used for erectile or sexual dysfunction. %PDF-1.5 % It is used for multi-ingredient prescriptions, when each ingredient is reported. Maternal, Child and Reproductive Health billing manual web page. Webb) A Basis of Cost Determination value of 08 (340B Disproportionate Share Pricing) indicates the drugs that are to be paid at the pharmacys 340B drug acquisition cost c) The drugs Actual Acquisition Cost must be entered into the Submitted Ingredient Cost field Access to Standards 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 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. An optional data element means that the user should be prompted for the field but does not have to enter a value. Values other than 0, 1, 08 and 09 will deny. This letter identifies the member's appeal rights. Reimbursement Basis Definition Required - If claim is for a compound prescription, enter "0. United States Health Information Knowledgebase Required if this field is reporting a contractually agreed upon payment. Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim. Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational 03 = National Drug Code (NDC) - Formatted 11 digits (N). 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