0 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. 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. Approval of a PAR does not guarantee payment. endstream endobj startxref B. Required when specified in trading partner agreement. "Required When." Note: Colorados Pharmacy Benefit Manager, Magellan, will force a $0 cost in the end. Required if needed to match the reversal to the original billing transaction. 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. Required when Other Amount Claimed Submitted (480-H9) is used. Required when other coverage is known, which is after the Date of Service submitted. For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). 523-FN Indicates that the drug was purchased through the 340B Drug Pricing Program. Delayed notification to the pharmacy of eligibility. COVID-19 medications that were procured by the federal government are free of cost to pharmacy providers. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT. 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. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). 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. AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. Sent if reversal results in generation of pricing detail. Please visit the OPR section of the Department's website for more detailed information about enrollment and compliance with the Affordable Care Act. Only members have the right to appeal a PAR decision. Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. 1710 0 obj <> endobj 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. One of the other designators, "M", "R" or "RW" will precede it. Required when needed to communicate DUR information. Required when utilization conflict is detected. 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. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional 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. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. 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. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. Pharmacies may submit claims electronically by obtaining a PAR from thePharmacy Support Center. Pharmacies can submit these claims electronically or by paper. Providers must submit accurate information. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). Required if the identification to be used in future transactions is different than what was submitted on the request. This requirement stems from the Social Security Act, 42 U.S.C. 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. BASIS OF CALCULATION - PERCENTAGE SALES TAX. Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. Required when there is a known patient financial responsibility incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required.". WebExamples of Reimbursable Basis in a sentence. Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Provided for informational purposes only. Pharmacies may electronically rebill denied claims when the claim submission is within 120 days of the date of service. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). If the member does not pick up the prescription from the pharmacy within 14 calendar days, the prescription must be reversed on the 15th calendar day. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). We anticipate that our pricing file updates will be completed no later than February 1, 2021. Required when its value has an effect on the Gross Amount Due (430-DU) calculation. The claim may be a multi-line compound claim. Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a cost share differential due to the selection of one pharmacy over another. 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. Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Required on all COB claims with Other Coverage Code of 3. : 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.. endstream endobj 1711 0 obj <>>>/Filter/Standard/Length 128/O(V^TpFH<1b,pdk%{ \rL)/P -1052/R 4/StmF/StdCF/StrF/StdCF/U(Z6r>H8 )/V 4>> endobj 1712 0 obj <>/Metadata 104 0 R/Outlines 447 0 R/PageLayout/OneColumn/Pages 1702 0 R/StructTreeRoot 608 0 R/Type/Catalog>> endobj 1713 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1714 0 obj <>stream Pharmacies must complete third-party information on the PCF and submit documentation from the third-party payer of payment or lack of payment. 523-FN : 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.. 07 = Amount of Co-insurance (572-4U) Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Required when Benefit Stage Amount (394-MW) is used. Required to identify the actual group that was used when multiple group coverage exist. If PAR is authorized, claim will pay with DAW1. Required on all COB claims with Other Coverage Code of 2. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. 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. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional 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). 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. 20 = 340B - Indicates that, prior to providing service, the pharmacy has determined the product being billed is purchased pursuant to rights available under Section 340B of the Public Health Act of 1992 including sub-ceiling purchases authorized by Section 340B (a) (10) and those made through the Prime Vendor Program (Section 340B(a)(8)). AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION. 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. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. 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). 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. These records must be maintained for at least seven (7) years. 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. All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. Enrolled Medicaid fee-for-service (FFS) members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies. Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. 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. A pharmacist or pharmacist designee shall offer counseling regarding the drug therapy to each Health First Colorado member with a new or refill prescription if the pharmacist or pharmacist designee believes that it is in the best interest of the member. An optional data element means that the user should be prompted for the field but does not have to enter a value. Providers should also consult the Code of Colorado Regulations (10 C.C.R. 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) 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 A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Copies of all forms necessary for submitting claims are also available on the Pharmacy Resources web page of the Department's website. Enter the ingredient drug cost for each product used in making the compound. Required if Basis of Cost Determination (432-DN) is submitted on billing. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. Required when the Other Payer Reject Code (472-6E) is used. Required when Basis of Cost Determination (432-DN) is submitted on billing. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Required if Other Payer Reject Code (472-6E) is used. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Required when other insurance information is available for coordination of benefits. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. Appeals may be sent to: With few exceptions, providers are required to submit claims electronically. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a non-preferred formulary product. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. 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. Pharmacies must call for overrides for lost, stolen, or damaged prescriptions. A generic drug is not therapeutically equivalent to the brand name drug. It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. A 7.5 percent tolerance is allowed between fills for Synagis. ), SMAC, WAC, or AAC. Timely filing for electronic and paper claim submission is 120 days from the date of service. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 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. The "***" indicates that the field is repeating. Values other than 0, 1, 08 and 09 will deny. 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. Representation by an attorney is usually required at administrative hearings. 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. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. 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 All services to women in the maternity cycle. Pharmacy Billing Procedures and Forms section of the Department's website, NCPDP Uu~Daw 0 Cannot Be Submitted Ms Drug W/Avail Generics~50740~Error List Daw0 Cant Be Submit Ms Drug W/Avail Gen. Prescriber has indicated the brand name drug is medically necessary. Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. Required - Enter total ingredient costs even if claim is for a compound prescription. If reversal is for multi-ingredient prescription, the value must be 00. Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program. Required when the previous payer has financial amounts that apply 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. The procedure to request a PAR and the medications that require a PAR are outlined in Appendix P - Pharmacy Benefit Prior Authorization Procedures and Criterialocated in the Pharmacy Prior Authorization Policies section of the Department's website. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. endstream endobj startxref Maternal, Child and Reproductive Health billing manual web page. Health & Safety in the Home, Workplace & Outdoors, Clinical Guidelines, Standards & Quality of Care, All Health Care Professionals & Patient Safety, Elderly Pharmaceutical Insurance Coverage (EPIC) Program, Payer Specifications D.0 is also available in Portable Document Format, Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template, Response Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template, Request Claim Reversal (B2) Payer Sheet Template, Response Claim Reversal Accepted/Approved (B2) Payer Sheet Template, Response Claim Reversal Accepted/Rejected (B2) Payer Sheet Template, Response Claim Reversal Rejected/Rejected (B2) Payer Sheet Template, James V. McDonald, M.D., M.P.H., Acting Commissioner, Multisystem Inflammatory Syndrome in Children (MIS-C), Addressing the Opioid Epidemic in New York State, Health Care and Mental Hygiene Worker Bonus Program, Maternal Mortality & Disparate Racial Outcomes, Help Increasing the Text Size in Your Web Browser. 06 = Patient Pay Amount (505-F5) 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. ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. 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 Required when a patient selected the brand drug and a generic form of the drug was available. NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. Required when Basis of Cost Determination (432-DN) is submitted on billing. Required if Other Payer Amount Paid Qualifier (342-HC) is used. Required for this program when the Other Coverage Code (308-C8) of "3" is used. If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. 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. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. Sent when DUR intervention is encountered during claim adjudication. Providers can collect co-pay from the member at the time of service or establish other payment methods. Applicable co-pay is automatically deducted from the provider's payment during claims processing. Requests for Reconsideration must be filed in writing with the pharmacy benefit manager within 60 days of the most recent claim or prior reconsideration denial. The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. Required if a repeating field is in error, to identify repeating field occurrence. Required when Submission Clarification Code (420-DK) is used. Parenteral Nutrition Products Required when Approved Message Code (548-6F) is used. Required when Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. 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 81J _FLy4AyGP(O Prescription cough and cold products for all ages will not require prior authorization for Health First Colorado members. Provided for informational purposes only. Parenteral Nutrition Products Required if Help Desk Phone Number (550-8F) is used. 1750 0 obj <>stream The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. 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. 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. In addition, some products are excluded from coverage and are listed in the Restricted Products section. Required when Additional Message Information (526-FQ) is used. Required for 340B Claims. Source documents and source records used to create pharmacy claims shall be maintained in such a way that all electronic media claims can be readily associated and identified. Incremental and subsequent fills may not be transferred from one pharmacy to another. A compounded prescription (a prescription where two or more ingredients are combined to achieve a desired therapeutic effect) must be submitted on the same claim. If the timely filing period expires due to a delayed or back-dated member eligibility determination, the claim is considered timely if received within 120 days from the date the member was granted backdated eligibility.
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basis of reimbursement determination codes