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. 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 Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. Drugs administered in clinics, these must be billed by the clinic on a professional claim. Confirm and document in writing the disposition WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. hb```+@(1Q(b!V R;Wyjn~u~kw~}CI @B 8F8CEVR,r@Zk0226H;)maVf\p@j053s0OIk5v X u cs. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. 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). If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax. Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate Program. Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. 05 = Amount of Co-pay (518-FI) 1727 0 obj <>/Encrypt 1711 0 R/Filter/FlateDecode/ID[]/Index[1710 41]/Info 1709 0 R/Length 94/Prev 551050/Root 1712 0 R/Size 1751/Type/XRef/W[1 3 1]>>stream 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. hbbd```b``"`DrVH$0"":``9@n]bLlv #3~ ` +c Required if necessary as component of Gross Amount Due. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. Additionally, all providers entering 340B claims must be registered and active with HRSA. '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits, 3 = Other Coverage Billed Claim not Covered. 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. Figure 4.1.3.a. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. Pharmacies may electronically rebill denied claims when the claim submission is within 120 days of the date of service. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. Required if Basis of Cost Determination (432-DN) is submitted on billing. 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 Required if utilization conflict is detected. SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Prescription cough and cold products may be approved with prior authorization for an acute condition for Dual Eligible (Medicare-Medicaid) members. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. If there is more than a single payer, a D.0 electronic transaction must be submitted. No products in the category are Medical Assistance Program benefits. 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. Parenteral Nutrition Products Required when necessary to identify the Plan's portion of the Sales Tax. If the original fills for these claims have no authorized refills a new RX number is required. Required when the patient's financial responsibility is due to the coverage gap. Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. Required if a repeating field is in error, to identify repeating field occurrence. 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. 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. The standard drug ingredient reimbursement methodology applies to the quantity dispensed with each fill. Required when Preferred Product ID (553-AR) is used. 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 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) Required if other insurance information is available for coordination of benefits. Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. Required when Flat Sales Tax Amount Submitted (481-HA) is greater than zero (0) or when Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement. Required when necessary for patient financial responsibility only billing. 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. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. 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. Health First Colorado does not provide reimbursement for products by manufacturers that have not signed a rebate agreement unless the Department has made a determination that the availability of the drug is essential, such drug has been given 1-A rating by the Food and Drug Administration (FDA), and prior authorized. enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. All necessary forms should be submitted to Magellan Rx Management at: There are four exceptions to the 120-day rule: Each of these exceptions is detailed below along with the specific instructions for submitting claims. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. Required when Basis of Cost Determination (432-DN) is submitted on billing. Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (402-D2) occur on the same day. Pharmacies should continue to rebill until a final resolution has been reached. All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. 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. Required - If claim is for a compound prescription, list total # of units for claim. Pharmacies may submit claims electronically by obtaining a PAR from thePharmacy Support Center. 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 - Pharmacy's Usual and Customary Charge, Required if Other Cov Code equals 2, 3, or 4, Other Payer Patient Responsibility $ Qualifier, Required when claim is for a compound prescription, 8 = Process Compound Claim for Approved Ingredients, Conditional - Needed to process claim for approved ingredients when claim is for a compound prescription, Required when the claim is for a compound prescription. Required if Basis of Cost Determination (432-DN) is submitted on billing. Required when there is payment from another source. Figure 4.1.3.a. 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. ADDITIONAL MESSAGE INFORMATION CONTINUITY. Services cannot be withheld if the member is unable to pay the co-pay. Required when needed to identify the transaction. 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. 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. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. WebExamples of Reimbursable Basis in a sentence. "C" indicates the completion of a partial fill. %PDF-1.6 % 13 = Amount Attributed to Processor Fee (571-NZ). 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. 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).
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