basis of reimbursement determination codesobituaries humphrey, nebraska
: 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.. 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. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. Required when there is payment from another source. Delayed notification to the pharmacy of eligibility. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. 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 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. If PAR is authorized, claim will pay with DAW1. Figure 4.1.3.a. Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Enrolled Medicaid fee-for-service (FFS) members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies. For all other information as it relates to family planning benefits, please visit the Maternal, Child and Reproductive Health billing manual web page. ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Claims that cannot be submitted through the vendor must be submitted on paper. Colorado Pharmacy supports up to 25 ingredients. Sent when DUR intervention is encountered during claim processing. 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 DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Required when Benefit Stage Amount (394-MW) is used. Required for 340B Claims. 05 = Amount of Co-pay (518-FI) Please refer to the specific rules and requirements regarding electronic and paper claims below. 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) Members within this eligibility category are only eligible to receive family planning and family planning-related medication. 1 = Proof of eligibility unknown or unavailable. Required when needed for receiver claim determination when multiple products are billed. 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. Required if Other Amount Claimed Submitted (480-H9) is greater than zero (0). Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. DESI drugs ** [applies to drugs with a Covered Outpatient Drug (COD) status equal to DESI - 5 (LTE/IRS drug for all indications or DESI 6 LTE/IRS drug withdrawn from market)]. 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. enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). ADDITIONAL MESSAGE INFORMATION CONTINUITY. Required if Basis of Cost Determination (432-DN) is submitted on billing. Pharmacies can submit these claims electronically or by paper. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. 1-5 = Refill number - Number of the replenishment, 8 = Substitution Allowed-Generic Drug Not Available in Marketplace, 1-99 = Authorized Refill number - with 99 being as needed, refills unlimited, 8 = Process Compound For Approved Ingredients. 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. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Please contact the Pharmacy Support Center with questions. 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). Sent when Other Health Insurance (OHI) is encountered during claims processing. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. 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. Required for partial fills. 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. COVID-19 medications that were procured by the federal government are free of cost to pharmacy providers. Required if needed to identify the transaction. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Interactive claim submission must comply with Colorado D.0 Requirements. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. 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. Pursuant to 42CFR 455.10(b) and 42CFR 455.440, Health First Colorado will not pay for prescriptions written by unenrolled prescribers. Cost-sharing for members must not exceed 5% of their monthly household income. 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. Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. Drug used for erectile or sexual dysfunction. 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 Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. 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. %%EOF Required if Other Payer patient Responsibility Amount (352-NQ) is submitted. Providers must submit accurate information. These source documents, in addition to any work papers and records used to create electronic media claims, shall be retained by the provider for seven years and shall be made readily available and produced upon request of the Secretary of the Department of Health and Human Services, the Department, and the Medicaid Fraud Control Unit and their authorized agents. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT. Federal regulation requires that drug manufacturers sign a national rebate agreement with the Centers for Medicare and Medicaid Services (CMS) to participate in the state Medical Assistance Program. 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. Date of service for the Associated Prescription/Service Reference Number (456-EN). Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. The total service area consists of all properties that are specifically and specially benefited. A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. An optional data element means that the user should be prompted for the field but does not have to enter a value. 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. Expanded Income and Title XIX (Fee-For-Service): Members with incomes up to 260% of the federal poverty level (expanded income) and in the Title XIX (Fee-For-Service) eligibility categories may receive up to a 12- month supply of contraceptives with 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. 0 Please visit the OPR section of the Department's website for more detailed information about enrollment and compliance with the Affordable Care Act. Timely filing for electronic and paper claim submission is 120 days from the date of service. A PAR is only necessary if an ingredient in the compound is subject to prior authorization. Required when Help Desk Phone Number (550-8F) is used. Pharmacies may submit claims electronically by obtaining a PAR from thePharmacy Support Center. The table below Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Required when specified in trading partner agreement. Required for partial fills. If there is more than a single payer, a D.0 electronic transaction must be submitted. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. Please contact the Pharmacy Support Center for a one-time PA deferment. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Required for partial fills. ), SMAC, WAC, or AAC. Values other than 0, 1, 08 and 09 will deny. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. 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. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORMULARY SELECTION. More information may be obtained in Appendix P in the Billing Manuals section of the Department's website. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. Required if Other Payer Amount Paid Qualifier (342-HC) is used. 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. 0 Required when Other Amount Claimed Submitted Qualifier (479-H8) is used. 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. 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. Required when Reason For Service Code (439-E4) is used. 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. 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. 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. Providers must follow the instructions below and may only submit one (prescription) per claim. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. If the claim is denied, pharmacy benefit manager will send one or more denial reason(s) that identify the problem(s). Required if Other Payer ID (340-7C) is used. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual. Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. Required if needed to supply additional information for the utilization conflict. Imp Guide: Required, if known, when patient has Medicaid coverage. 1710 0 obj <> endobj The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required for partial fills. 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. Parenteral Nutrition Products Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). ), SMAC, WAC, or AAC. COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT, 03 = Bank Information Number (BIN) Card Issuer ID. The table below Indicates that the drug was purchased through the 340B Drug Pricing Program. 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. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Provided for informational purposes only. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. 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. Pharmacies must complete third-party information on the PCF and submit documentation from the third-party payer of payment or lack of payment. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. If the appropriate numbers of days have not lapsed, the claim will be denied as a refill-too-soon unless there has been a change in the dosing. 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 should retrieve their Remittance Advice (RA) or X12N 835 through the Provider Web Portal. Required for partial fills. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). 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. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). An additional request for reconsideration may be submitted within 60 days of the reconsideration denial if information can be corrected or if additional supporting information is available. Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility. 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 The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. Member Contact Center1-800-221-3943/State Relay: 711. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER, ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. 523-FN Sent when Other Health Insurance (OHI) is encountered during claim processing. Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. Values other than 0, 1, 08 and 09 will deny. Required when other coverage is known, which is after the Date of Service submitted. endstream endobj startxref 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 Required if Reason for Service Code (439-E4) is used. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG. Reversal Window (If transaction is billed today, what is the, Required when needed to match the reversal to the original billing transaction. Required to identify the actual group that was used when multiple group coverage exist. Maternal, Child and Reproductive Health billing manual web page. CMS began releasing RVU information in December 2020. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. Parenteral Nutrition Products Parenteral Nutrition Products 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 WebExamples of Reimbursable Basis in a sentence. 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 to identify the Patient's portion of the Sales Tax. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements. BNR=Brand Name Required), claim will pay with DAW9. Required when Basis of Reimbursement Determination (522-FM) is "14" (Patient Responsibility Amount) or "15" (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Approval of a PAR does not guarantee payment. 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. 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 1750 0 obj <>stream The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. Required when necessary for plan benefit administration. Required if identification of the Other Payer Date is necessary for claim/encounter adjudication. SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. These records must be maintained for at least seven (7) years. Required if Patient Pay Amount (505-F5) includes deductible. Required when a patient selected the brand drug and a generic form of the drug was available. Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. Required if Approved Message Code (548-6F) is used. Required if Previous Date Of Fill (530-FU) is used. A generic drug is not therapeutically equivalent to the brand name drug. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Figure 4.1.3.a. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. 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. 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.