basis of reimbursement determination codes
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 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. Required if needed to identify the transaction. The table below 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. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. 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. 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. COVID-19 early refill overrides are not available for mail-order pharmacies. Required if Basis of Cost Determination (432-DN) is submitted on billing. B. 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. 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. Effective 10/22/2021, Updated policy for Quantity Limit overrides in COVID-19 section. All claims for incremental and subsequent fills require valid values in the following fields: Please note: if a pharmacy submits a claim for a non-Schedule II medication and includes a value for quantity prescribed, it must be a valid value. Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. Required when needed for receiver claim determination when multiple products are billed. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. 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. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. 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 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. Sent when Other Health Insurance (OHI) is encountered during claims processing. Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. This dollar amount will be provided, when known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount. Required if Quantity of Previous Fill (531-FV) is used. The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication. Required when needed to specify the reason that submission of the transaction has been delayed. Required if needed to provide a support telephone number of the other payer to the receiver. If a member has Medicaid as their secondary insurance and their primary insurance covers a medication, but Health First Colorado requires a prior authorization for the medication, the pharmacy or provider may request a prior authorization override by contacting the Magellan Helpdesk at 1-800-424-5725. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a non-preferred formulary product. Required if Other Payer Amount Paid Qualifier (342-HC) is used. Members within this eligibility category will not be subject to utilization management policies as outlined in the Appendix P, Preferred Drug List (PDL) or Appendix Y. 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 Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Maternal, Child and Reproductive Health billing manual web page. Enrolled Medicaid fee-for-service (FFS) members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies. 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. Required - If claim is for a compound prescription, enter "0. Paper claims may be submitted using a pharmacy claim form. Required if Additional Message Information (526-FQ) is used. Required when the Other Payer Reject Code (472-6E) is used. We anticipate that our pricing file updates will be completed no later than February 1, 2021. 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). 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. The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). The use of inaccurate or false information can result in the reversal of claims. If the medication has been determined to be family planning or family planning-related, it should be documented in the prescription record. Required if Previous Date of Fill (530-FU) is used. 639 0 obj <> endobj WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). 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. Values other than 0, 1, 08 and 09 will deny. 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. Required when Help Desk Phone Number (550-8F) is used. The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. The maternity cycle is the time period during the pregnancy and 365days' post-partum. Required for partial fills. 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). 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. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. ADDITIONAL MESSAGE INFORMATION CONTINUITY. 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. 1 = Proof of eligibility unknown or unavailable. This dollar amount will be provided, if known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount. Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. 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. Required when necessary for plan benefit administration. This document contains the specifications of six templates: Payer: Please list each transaction supported with the segments, fields and pertinent information on each transaction. The value of '05' (Acquisition) or '08' (340B Disproportionate Share Pricing/Public Health Service) in the Basis of Cost Determination field (NCPDP Field # 423-DN). 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. The form is one-sided and requires an authorized signature. OTHER PAYER - PATIENT RESPONSIBILITY AMOUNT COUNT, Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used, OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFER, Required if Other Payer-Patient Responsibility Amount (352-NQ) is used352-NQ. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. hbbd```b``"`DrVH$0"":``9@n]bLlv #3~ ` +c Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. Required when needed to supply additional information for the utilization conflict. Required to identify the actual group that was used when multiple group coverage exist. 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. Required if Ingredient Cost Paid (506-F6) is greater than zero (0). "C" indicates the completion of a partial fill. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. Required if needed to provide a support telephone number to the receiver. If the original fills for these claims have no authorized refills a new RX number is required. If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. 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 WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. ), SMAC, WAC, or AAC. Required for partial fills. Dispensing (Incentive) Fee = Standard dispense fee based on a pharmacys total annual prescription volume will still apply. Prior authorization requests for some products may be approved based on medical necessity. 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 Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. 10 = Amount Attributed to Provider Network Selection (133-UJ) B. 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 Basis of Cost Determination (432-DN) is submitted on billing. 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. 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. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER. Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. 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 Timely filing for electronic and paper claim submission is 120 days from the date of service. 523-FN Required on all COB claims with Other Coverage Code of 3. Metric decimal quantity of medication that would be dispensed for a full quantity. Required if Other Payer Amount Paid (431-Dv) is used. Does not obligate you to see Health First Colorado members. ), SMAC, WAC, or AAC. Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. The Health First Colorado program does not pay a compounding fee. Required when Basis of Cost Determination (432-DN) is submitted on billing. Required when necessary to identify the Patient's portion of the Sales Tax. No blanks allowed. The standard drug ingredient reimbursement methodology applies to the quantity dispensed with each fill. CMS began releasing RVU information in December 2020. 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. Required for partial fills. This pharmacy billing manual explains many of the Colorado Department of Health Care Policy & Financing's (the Department) policies regarding billing, provider responsibilities, and program benefits. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. Prior Authorization Request (PAR) Process, Guidelines Used by the Department for Determining PAR Criteria, Incremental Fills and/or Prescription Splitting, Lost/Stolen/Damaged/Vacation Prescriptions, Temporary COVID-19 Policy and Billing Changes, Medication Prior Authorization Deferments, EUA COVID-19 Antivirals Claim Requirements, Ordering, Prescribing or Referring (OPR) Providers, Delayed Notification to the Pharmacy of Eligibility, Instructions for Completing the Pharmacy Claim Form, Response Claim Billing/Claim Rebill Payer Sheet Template, Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response, Claim Billing/Claim Rebill PAID (or Duplicate of PAID) Response, Claim Billing/Claim Rebill Accepted/Rejected Response, Claim Billing/Claim Rebill Rejected/Rejected Response, NCPDP Version D.0 Claim Reversal Template, Request Claim Reversal Payer Sheet Template, Response Claim Reversal Payer Sheet Template, Claim Reversal Accepted/Approved Response, Claim Reversal Accepted/Rejected Response, Claim Reversal Rejected/Rejected Response, Pharmacy Prior Authorization Policies section. Download Standards Membership in NCPDP is required for access to standards. The field is mandatory for the Segment in the designated Transaction. All products in this category are regular Medical Assistance Program benefits. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. Electronic claim submissions must meet timely filing requirements. Required when additional text is needed for clarification or detail. 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. A 7.5 percent tolerance is allowed between fills for Synagis. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if 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. 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. If the medication is not on the family planning-related drug list, then the prescriber will need to complete a prior authorization to confirm that the drug was prescribed in relation to a family planning visit. Required if Other Payer Reject Code (472-6E) is used. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. If the medication has been determined to be family planning or family planning- related, it should be documented in the prescription record. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). Required if Previous Date Of Fill (530-FU) is used. If a member requires a refill before 50% of the day supply has lapsed, please provide the Pharmacy Support Center details of the extenuating circumstances. 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. 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 Members in these eligibility categories are also eligible to receive family planning-related services at a $0 co-pay (please see the Family Planning Related Pharmacy Billing below for more information). This field explains how the drug ingredient cost was derived; whether DOJ, FUL, AWP (As of October 1, 2011, AWP pricing will no longer be available. Confirm and document in writing the disposition This field is required when the plan is a participant in a Medicare Part D program that requires reporting of benefit stage specific financial amounts. Unless otherwise communicated in the PDL or Appendix P, maintenance medications may be filled for up to a 100-day supply, and non-maintenance medications may be filled for up to a 30-day supply. ), SMAC, WAC, or AAC. Required when Basis of Cost Determination (432-DN) is submitted on billing. Required when there is payment from another source. Required when Other Payer-Patient Responsibility Amount (352-NQ) is used. The total service area consists of all properties that are specifically and specially benefited. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. not used) for this payer are excluded from the template. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Generic Drug Not in Stock, NCPDP EC 22-M/I DISPENSE AS WRITTEN CODE~50021~ERROR LIST M/I DISPENSE AS WRITTEN CODE and return the supplemental message Submitted DAW code not supported. Required if Patient Pay Amount (505-F5) includes deductible. Required when Flat Sales Tax Amount Submitted (481-HA) is greater than zero (0) or when Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement. If the reconsideration is denied, the final option is to appeal the reconsideration. Q,iDfh|)vCDD&I}nd~S&":@*DcS|]!ph);`s/EyxS5] zVHJ~4]T}+1d'R(3sk0YwIz$[))xB:H U]yno- VN1!Q`d/%a^4\+ feCDX$t]Sd?QT"I/%. This value is the prescription number from the first partial fill. Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. endstream endobj startxref If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. Reversal Window (If transaction is billed today, what is the, Required when needed to match the reversal to the original billing transaction. More information may be obtained in Appendix P in the Billing Manuals section of the Department's website. 01 = Amount Applied to Periodic Deductible (517-FH), 02 = Amount Attributed to ProductSelection/Brand Drug (134-UK), 03 = Amount Attributed to Sales Tax(523-FN), 04 = Amount Exceeding Periodic Benefit Maximum (520-FK), 06 = Patient Pay Amount (Deductible) (505-F5), 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection(135-UM), 10 = Amount Attributed to Provider Network Selection (133-UJ), 11 = Amount Attributed to Product Selection/Brand Non-Preferred FormularySelection(136-UN), 12 = Amount Attributed to Coverage Gap (137-UP), 13 = Amount Attributed to Processor Fee (571-NZ), MA = Medication Administration - use for vaccine. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. 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. Only members have the right to appeal a PAR decision. The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website. EY Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. Required when Other Amount Paid (565-J4) is used. Imp Guide: Required, if known, when patient has Medicaid coverage. 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 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 Confirm and document in writing the disposition raiders salary cap space 2021, sims 4 furniture cc folder 2022, life cycle of a cricket worksheet,
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