Required when Other Amount Claimed Submitted Qualifier (479-H8) is used. Required if Other Amount Claimed Submitted (480-H9) is greater than zero (0). The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. 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. We anticipate that our pricing file updates will be completed no later than February 1, 2021. 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. BASIS Only members have the right to appeal a PAR decision. 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 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 These medications (e.g., Paxlovid) still need to be billed to Colorado Medicaid, even though they are free of cost, and the claim requirements for billing free medications is outlined below: The Health First Colorado program uses the National Council on Prescription Drug Programs (NCPDP) electronic format and the Pharmacy Claim Form (PCF) to submit prescription drug claims. Drug list criteria designates the brand product as preferred, (i.e. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER. Required when Preferred Product ID (553-AR) is used. 523-FN Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. BASIS OF CALCULATION - PERCENTAGE SALES TAX. 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. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Required if Patient Pay Amount (505-F5) includes deductible. COVID-19 early refill overrides are not available for mail-order pharmacies. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). If a member calls the call center, the member will be directed to have the pharmacy call for the override. 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 when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Reimbursable Basis Definition Drugs administered in the hospital are part of the hospital fee. Electronic claim submissions must meet timely filing requirements. Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. If the medication has been determined to be family planning or family planning- related, it should be documented in the prescription record. Members of these eligibility categories will be subject to utilization management policies as outlined in the Appendix P, PDL or Appendix Y. NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. EY Required - If claim is for a compound prescription, list total # of units for claim. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Required if needed to supply additional information for the utilization conflict. The use of inaccurate or false information can result in the reversal of claims. 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). * Cough and cold products: Cough and cold products include combinations of narcotic and nonnarcotic cough suppressants, expectorants, and/or decongestants. Physicians and other practitioners who order, prescribe or refer items or services for Health First Colorado members, but who choose not to submit claims to Health First Colorado, are referred to as OPR providers. 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. Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Required when needed to communicate DUR information. PB 18-08 340B Claim Submission Requirements and Pharmacies must call for overrides for lost, stolen, or damaged prescriptions. 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). Required for 340B Claims. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. 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 records must be maintained for at least seven (7) years. 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. B. 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) Required when Other Amount Claimed Submitted (480-H9) is used. Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. 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. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. COMPOUND INGREDIENT BASIS OF COST DETERMINATION. Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Required if text is needed for clarification or detail. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Download Standards Membership in NCPDP is required for access to standards. 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 Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). United States Health Information Knowledgebase 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. 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 Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. Required if needed to provide a support telephone number of the other payer to the receiver. Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Required if Other Payer Amount Paid (431-Dv) is used. PARs are reviewed by the Department or the pharmacy benefit manager. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. New PAs and existing PA approvals that are less than 12 months are not eligible for deferment. 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. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements. Required when needed to identify the transaction. 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 DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Parenteral Nutrition Products The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. IV equipment (for example, Venopaks dispensed without the IV solutions). Required if this field could result in contractually agreed upon payment. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. ADDITIONAL MESSAGE INFORMATION CONTINUITY. Required when the customer is responsible for 100 percent of the prescription payment and when the provider net sale is less than the amount the customer is expected to pay. 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 Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Sent if reversal results in generation of pricing detail. 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. Required for this program when the Other Coverage Code (308-C8) of "3" is used. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. 1 = Proof of eligibility unknown or unavailable. Required if any other payment fields sent by the sender. We anticipate that our pricing file updates will be completed no later than February 1, 2021. 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
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