basis of reimbursement determination codes
Dodane 10 maja 2023It 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. We anticipate that our pricing file updates will be completed no later than February 1, 2021. Updated Lost/Stolen/Damaged/Vacation Prescriptions section - police report is no longer required for Stolen Medications, PAR Process: Updated notification letter section, Partial Fills and/or Prescription: Updated partial fill criteria, Updated contact information on page 15, to include Magellan's helpdesk info. Figure 4.1.3.a. 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). Required on all COB claims with Other Coverage Code of 2. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Required if Previous Date Of Fill (530-FU) is used. 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 claim is for a compound prescription, list total # of units for 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. In no case, shall prescriptions be kept in will-call status for more than 14 days. Required when this value is used to arrive at the final reimbursement. The table below 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 when needed per trading partner agreement. endstream endobj startxref AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. %PDF-1.5 % Other Payer Bank Information Number (BIN). Prescription cough and cold products may be approved with prior authorization for an acute condition for Dual Eligible (Medicare-Medicaid) members. Members who are eligible for all pregnancy related and postpartum services under Medicaid are eligible to receive services for the 365- day postpartum period at a $0 co-pay. =y?@d:qb@6l7YC&)H]zjse/0 m{YSqT;?z~bDG_agiZo8pomle;]Zt QmF8@bt/ &|=SM1LZTr'hxu&0\lcmUFC!BKXrT} 7IFD&t{TagKwRI>T$ wja Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. 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. 04 = Amount Exceeding Periodic Benefit Maximum (520-FK) 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. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. The Helpdesk is available 24 hours a day, seven days a week. Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program. One of the other designators, "M", "R" or "RW" will precede it. 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 Drug list criteria designates the brand product as preferred, (i.e. ), SMAC, WAC, or AAC. If there is more than a single payer, a D.0 electronic transaction must be submitted. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. NOTE: This prior authorization override request with the Helpdesk only applies when claim records indicate that primary insurance was successfully billed first and if the medication is a covered pharmacy benefit. 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. The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication. Imp Guide: Required, if known, when patient has Medicaid coverage. 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. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. Required when specified in trading partner agreement. Required when other insurance information is available for coordination of benefits. Coordination of Benefits/Other Payments Count, Required if Other Payer ID (Field # 340-7C) is used, Required if identification of the Other Payer Date is necessary for claim/encounter adjudication, CCYYMMDD. The total service area consists of all properties that are specifically and specially benefited. Approval of a PAR does not guarantee payment. 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. B. Required if Basis of Cost Determination (432-DN) is submitted on billing. Each PA may be extended one time for 90 days. Copies of all RAs, electronic claim rejections, and/or correspondence documenting compliance with timely filing and 60-day rule requirements must be submitted with the Request for Reconsideration. For more information related to physician administered drugs and billing for this population, please visit the Physician-Administered-Drug (PAD) Billing Manual. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. Required when Other Payer-Patient Responsibility Amount (352-NQ) is used. 523-FN Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). 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 maternity cycle is the time period during the pregnancy and 365days' post-partum. Pharmacies are expected to keep records indicating when member counseling was not or could not be provided. An optional data element means that the user should be prompted for the field but does not have to enter a value. COVID-19 early refill overrides are not available for mail-order pharmacies. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational ADDITIONAL MESSAGE INFORMATION CONTINUITY. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. Members in this eligibility category may receive up to a 12-month supply ofcontraceptiveswith a $0 co-pay. The pharmacy benefit manager processes both electronic and paper claims and provides claim, provider, eligibility, and PAR interfaces with the Medicaid Management Information System (MMIS). 523-FN If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. 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. Signature requirements are temporarily waived for Member Counseling and Proof of Delivery. Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. For TXIX, if the prescriber confirms that the drug was not prescribed in relation to a family planning visit, then the pharmacy should remove the 6-Family Plan from the claim so that the claim can adjudicate accordingly. Please see the payer sheet grid below for more detailed requirements regarding each field. Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. 03 = National Drug Code (NDC) - Formatted 11 digits (N). Required when text is needed for clarification or detail. 06 = Patient Pay Amount (505-F5) Drugs administered in the hospital are part of the hospital fee. Drugs administered in clinics, these must be billed by the clinic on a professional claim. "P" indicates the quantity dispensed is a partial fill. Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. 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. The "Dispense as Written (DAW) Override Codes" table describes the valid scenarios allowable per DAW code. Required when needed to supply additional information for the utilization conflict. Delayed notification to the pharmacy of eligibility. Required if Approved Message Code (548-6F) is used. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. Providers must submit accurate information. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Sent when DUR intervention is encountered during claim adjudication. Mental illness as defined in C.R.S 10-16-104 (5.5). A generic drug is not therapeutically equivalent to the brand name drug. Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. 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. For non-mail order transactions, there is a maximum 20-day accumulation allowed every rolling 180 days. Single agent antihistamines and their combination products with a decongestant are not considered to be cough and cold products and are regular Medical Assistance Program benefits. 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 Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required.". Required when Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. 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 when Other Amount Paid (565-J4) is used. Required if a repeating field is in error, to identify repeating field occurrence. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Providers should also consult the Code of Colorado Regulations (10 C.C.R. Pharmacies may call the Pharmacy Support Center to request a quantity limit override 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. "Required When." hbbd```b``} DL`D^A$KT`H2nfA H/# -~$G@3@"@*Z? Please visit the OPR section of the Department's website for more detailed information about enrollment and compliance with the Affordable Care Act. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORMULARY SELECTION. Required when needed to provide a support telephone number of the other payer to the receiver. Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. BASIS OF CALCULATION - PERCENTAGE SALES TAX. Download Standards Membership in NCPDP is required for access to standards. Required if this field could result in contractually agreed upon payment. This document contains the specifications of six templates: Payer: Please list each transaction supported with the segments, fields and pertinent information on each transaction. IV equipment (for example, Venopaks dispensed without the IV solutions). 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. 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. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. 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. Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. 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. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Required when necessary for plan benefit administration. Required if any other payment fields sent by the sender. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER. Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. iT|'r4O!JtN!EIVJB yv7kAY:@>1erpFBkz.cDEXPTo|G|r>OkWI/"j1;gT* :k $O{ftLZ>T7h.6k>a'vh?a!>7 s DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. *Note: Code 09 is a negative amount and is not a valid option for field 351-NP. "C" indicates the completion of a partial fill. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Required when any other payment fields sent by the sender. 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. A member has tried the generic equivalent but is unable to continue treatment on the generic drug and criteria is met for medication. Sent when claim adjudication outcome requires subsequent PA number for payment. 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. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER. 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
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