AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION. Required when Preferred Product ID (553-AR) is used. Required when a repeating field is in error, to identify repeating field occurrence. %PDF-1.5 % The claim may be a multi-line compound claim. Members who were formerly in foster care are co-pay exempt until their 26th birthday, Services provided by Community Mental Health Services, Members receiving a prescription for Tobacco Cessation Product. Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). 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). %PDF-1.6 % Caremark Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Sent when DUR intervention is encountered during claim processing. Required - If claim is for a compound prescription, list total # of units for claim. The table below PB 18-08 340B Claim Submission Requirements and Member Contact Center1-800-221-3943/State Relay: 711. Does not mean you will be listed as a Health First Colorado provider for patient assignment or referral, Allows you to continue to see Health First Colorado members without billing Health First Colorado, and. ), SMAC, WAC, or AAC. 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. INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT. The Health First Colorado program restricts or excludes coverage for some drug categories. Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. Reimbursable Basis Definition Family planning (e.g., contraceptives) services are configured for a $0 co-pay. Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET 19 Antivirals Dispensing and Reimbursement Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQW) follows it, and the text of the following message is a continuation of the current. The "***" indicates that the field is repeating. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). 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. 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). These values are for covered outpatient drugs. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements. All pharmacy PARs must be telephoned, faxed, or submitted via Real Time Prior Authorization via EHR, by the prescribing physician or physician's agent to the Pharmacy Benefit Manager Support Center. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). : 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.. Providers must submit accurate information. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. A PAR is only necessary if an ingredient in the compound is subject to prior authorization. The following lists the segments and fields in a Claim Billing or Claim Rebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. EY 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 B. 677 0 obj <>stream Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Providers must follow the instructions below and may only submit one (prescription) per claim. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Required when needed to provide a support telephone number. In determining what drugs should be subject to prior authorization, the following criteria is used: Most brand-name drugs with a generic therapeutic equivalent are not covered by the Health First Colorado program. For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Required when this value is used to arrive at the final reimbursement. Required when Quantity of Previous Fill (531-FV) is used. 1710 0 obj <> endobj 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. Pharmacies should continue to rebill until a final resolution has been reached. Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. If PAR is authorized, claim will pay with DAW1. 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. Figure 4.1.3.a. Members of these eligibility categories will be subject to utilization management policies as outlined in the Appendix P, PDL or Appendix Y. ", 00 = If claim is a multi-ingredient compound transaction, Required - If claim is for a compound prescription, enter "00.". 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. Required when Basis of Cost Determination (432-DN) is submitted on billing. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). 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. The form is one-sided and requires an authorized signature. Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. : 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.. Payer Specifications D.0 The table below Maternal, Child and Reproductive Health billing manual web page. Required when Other Payer ID (340-7C) is used. 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. No products in the category are Medical Assistance Program benefits. 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 Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. 04 = Amount Exceeding Periodic Benefit Maximum (520-FK) 19 Antivirals Dispensing and Reimbursement Required - If claim is for a compound prescription, enter "0. 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. Added Temporary COVID section, updated Provider Web Portal link, Updated verbiage to include the NCPDP D.0 guidelines for field 460-ET, Updated DAW Codes: Updated Dispense as Written (DAW) Override Code table. The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. Required when additional text is needed for clarification or detail. 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. hbbd```b``} DL`D^A$KT`H2nfA H/# -~$G@3@"@*Z? Required when Submission Clarification Code (420-DK) is used. Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. 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 Please see the payer sheet grid below for more detailed requirements regarding each field. Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc. 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. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state.