Sent when DUR intervention is encountered during claim adjudication. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). Amount expressed in metric decimal units of the product included in the compound. 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. Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. Access to Standards An optional data element means that the user should be prompted for the field but does not have to enter a value. Reimbursement Rates for 2021 Procedure Codes DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional "C" indicates the completion of a partial fill. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. The total service area consists of all properties that are specifically and specially benefited. Services cannot be withheld if the member is unable to pay the co-pay. The situations designated have qualifications for usage ("Required when x,"Not Required when y"). Enrolling in Health First Colorado as an OPR provider: If an OPR prescriber does not wish to enroll with Health First Colorado they must refer their patients to an enrolled prescriber, otherwise claims will deny. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Approval of a PAR does not guarantee payment. B. 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 Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc. 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. %PDF-1.5 % Sent if reversal results in generation of pricing detail. 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 Benefit Stage Amount (394-MW) is used. Access to Standards Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. 523-FN Providers must submit accurate information. Pharmacy employee negligence, employer failure to provide sufficient, well-trained employees, or failure to properly monitor the activities of employees and agents (e.g., billing services) are not considered extenuating circumstances beyond the pharmacy provider's control. 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. WebIts content included administrative items and other artifacts for Centers for Medicare & Medicaid Services (CMS) Quality Reporting Programs, State all-payer claims databases (APCDs), Children's Electronic Health Record (EHR) Format, and Agency for Healthcare Research and Quality (AHRQ) Patient Safety Common Formats, as well as standards for Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. 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. Imp Guide: Required, if known, when patient has Medicaid coverage. If no number is supplied, populate with zeros, Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs), OCC codes 0, 1, 2, 3, and 4 Supported (no co-pay only billing allowed), COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT. An emergency is any condition that is life-threatening or requires immediate medical intervention. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Pharmacies that have an electronic tracking system shall review prescriptions in will-call status on a daily basis and enter a reversal of prescriptions not picked up within 10 days of billing. 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. Reimbursement Basis Definition 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. 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. BASIS BASIS Instructions on how to complete the PCF are available in this manual. 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. Does not obligate you to see Health First Colorado members. 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 Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. 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. These source documents, in addition to any work papers and records used to create electronic media claims, shall be retained by the provider for seven years and shall be made readily available and produced upon request of the Secretary of the Department of Health and Human Services, the Department, and the Medicaid Fraud Control Unit and their authorized agents. 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 If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax. Pharmacies can submit these claims electronically or by paper. Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. B. Required if needed to provide a support telephone number to the receiver. Appeals may be sent to: With few exceptions, providers are required to submit claims electronically. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. 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 needed to communicate DUR information. Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. Prescription cough and cold products may be approved with prior authorization for an acute condition for Dual Eligible (Medicare-Medicaid) members. If there is a marketplace shortage for the generic version of the prescribed drug and only the brand-name product is available, claim will pay with DAW 8. 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. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. Required if Other Payer ID (340-7C) is used. 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)). The use of inaccurate or false information can result in the reversal of claims. 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)]. Dispensing (Incentive) Fee = Standard dispense fee based on a pharmacys total annual prescription volume will still apply. CMS began releasing RVU information in December 2020. 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. Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. 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. Companion Document To Supplement The NCPDP VERSION 04 = Amount Exceeding Periodic Benefit Maximum (520-FK) Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL Required when text is needed for clarification or detail. 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 The offer to counsel shall be face-to-face communication whenever practical or by telephone. Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. Required when Other Payer ID (340-7C) is used. Durable Medical Equipment (DME), these must be billed as a medical benefit on a professional claim. We anticipate that our pricing file updates will be completed no later than February 1, 2021. Members can receive a brand name drug without a PAR if: Members may receive a brand name drug with a PAR if: The pharmacy Prior Authorization Form is available on the Pharmacy Resources web page of the Department's website. The table below Requests for timely filing waivers for extenuating circumstances must be made in writing and must contain a detailed description of the circumstance that was beyond the control of the pharmacy. The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication. 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 Additional Message Information (526-FQ) is used. Reimbursable Basis Definition Parenteral Nutrition Products Express Scripts * Cough and cold products: Cough and cold products include combinations of narcotic and nonnarcotic cough suppressants, expectorants, and/or decongestants. : 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.. Sent when DUR intervention is encountered during claim processing. Figure 4.1.3.a. Local and out-of-state pharmacies may provide mail-order prescriptions for Medicaid members if they are enrolled with the Health First Colorado program and are registered and in good standing with the State Board of Pharmacy. 340B Information Exchange Reference Guide - NCPDP The "Dispense as Written (DAW) Override Codes" table describes the valid scenarios allowable per DAW code. The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Required when Approved Message Code (548-6F) is used. Pharmacies must complete third-party information on the PCF and submit documentation from the third-party payer of payment or lack of payment. 340B Information Exchange Reference Guide - NCPDP 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. The field is mandatory 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). Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. Required on all COB claims with Other Coverage Code of 3. Pharmacy Required if Previous Date Of Fill (530-FU) is used. United States Health Information Knowledgebase DISPENSING FEE CONTRACTED/REIMBURSABLE AMOUNT. BNR=Brand Name Required), claim will pay with DAW9. Required when Other Amount Paid (565-J4) is used. Required if needed to match the reversal to the original billing transaction. Figure 4.1.3.a. Required when Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. CMS began releasing RVU information in December 2020. Required for this program when the Other Coverage Code (308-C8) of "3" is used. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Required when its value has an effect on the Gross Amount Due (430-DU) calculation. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG. 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. 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. 677 0 obj <>stream 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 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. Maternal, Child and Reproductive Health billing manual web page. The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. BASIS Required if any other payment fields sent by the sender. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. Required for 340B Claims. This value is the prescription number from the first partial fill. Providers must follow the instructions below and may only submit one (prescription) per claim. Note: Fields that are not used in the Claim Billing/Claim Re-bill transactions and those that do not have qualified requirements (.i.e., not used) for this payer are excluded from the template. 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. Copies of all forms necessary for submitting claims are also available on the Pharmacy Resources web page of the Department's website. 12 = Amount Attributed to Coverage Gap (137-UP) If a pharmacy is made aware of eligibility after 120 days from the date of service, the pharmacy may submit the claims electronically by obtaining a PAR from the Pharmacy Support Center, or by paper using a pharmacy claim form. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Date of service for the Associated Prescription/Service Reference Number (456-EN). Required when Basis of Cost Determination (432-DN) is submitted on billing. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL Sent when claim adjudication outcome requires subsequent PA number for payment. 0 For non-scheduled drugs, 75 percent of the days' supply of the last fill must lapse before a drug can be filled again. COVID-19 early refill overrides are not available for mail-order pharmacies. Pharmacies may submit claims electronically by obtaining a PAR from thePharmacy Support Center. 639 0 obj <> endobj Access to Standards Required if Basis of Cost Determination (432-DN) is submitted on billing. 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. 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. We anticipate that our pricing file updates will be completed no later than February 1, 2021. "Required When." ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. 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. not used) for this payer are excluded from the template. If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. This will allow the pharmacist to determine if the medication was prescribed in relation to a family planning visit (e.g., tobacco cessation, UTI and STI/STD medications). 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 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. PB 18-08 340B Claim Submission Requirements and If the timely filing period expires due to a delayed or back-dated member eligibility determination, the claim is considered timely if received within 120 days from the date the member was granted backdated eligibility. The maternity cycle is the time period during the pregnancy and 365days' post-partum. : 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.. Cheratussin AC, Virtussin AC). Please refer to the specific rules and requirements regarding electronic and paper claims below. PARs are reviewed by the Department or the pharmacy benefit manager. The field has been designated with the situation of "Required" for the Segment in the designated Transaction. Required if Patient Pay Amount (505-F5) includes deductible. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET