Required if Additional Message Information (526-FQ) is used. In an emergency, when a PAR cannot be obtained in time to fill the prescription, pharmacies may dispense a 72-hour supply (3 days) of covered outpatient prescription drugs to an eligible member by calling the Pharmacy Support Center. 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. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. 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. 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. Required if necessary as component of Gross Amount Due. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). %PDF-1.6 % 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. Paper claims may be submitted using a pharmacy claim form. Required when a repeating field is in error, to identify repeating field occurrence. 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. 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 if needed to identify the transaction. Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. Colorado Pharmacy supports up to 25 ingredients. Required if Basis of Cost Determination (432-DN) is submitted on billing. Required if the identification to be used in future transactions is different than what was submitted on the request. Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). In no case, shall prescriptions be kept in will-call status for more than 14 days. Updated Partial Fill Section to read Incremental Fills and/or Prescription Splitting, Updated Quantity Prescribed valid value policy, Updated the diagnosis codes in COVID-19 zero copay section. The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. Required - If claim is for a compound prescription, enter "0. 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 WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required when Benefit Stage Amount (394-MW) is used. 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 For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Parenteral Nutrition Products Only members have the right to appeal a PAR decision. Required for partial fills. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed. Required when a product preference exists that needs to be communicated to the receiver via an ID. The Department does not pay for early refills when needed for a vacation supply. Please see the payer sheet grid below for more detailed requirements regarding each field. WebExamples of Reimbursable Basis in a sentence. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. 661 0 obj <>/Filter/FlateDecode/ID[<62EB3A7657CA4643BE855C13B68E8087>]/Index[639 39]/Info 638 0 R/Length 107/Prev 799058/Root 640 0 R/Size 678/Type/XRef/W[1 3 1]>>stream Sent when DUR intervention is encountered during claim adjudication. 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 Reimbursable Basis Definition Required when other coverage is known, which is after the Date of Service submitted. Substitution Allowed - Pharmacist Selected Product Dispensed, NCPDP 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. 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. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT, Required for all COB claims with Other Coverage Code of 2 or 4. 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 if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. 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. Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate Program. The table below INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT. 340B Information Exchange Reference Guide - NCPDP 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)]. Timely filing for electronic and paper claim submission is 120 days from the date of service. 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 for partial fills. This value is the prescription number from the first partial fill. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. Required when utilization conflict is detected. 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. 1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads. BASIS Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. WebExamples of Reimbursable Basis in a sentence. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. A member has tried the generic equivalent but is unable to continue treatment on the generic drug and criteria is met for medication. "Required when." : 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.. Confirm and document in writing the disposition The pharmacy benefit manager processes both electronic and paper claims and provides claim, provider, eligibility, and PAR interfaces with the Medicaid Management Information System (MMIS). 1710 0 obj <> endobj The field has been designated with the situation of "Required" for the Segment in the designated Transaction. Required if needed by receiver to match the claim that is being reversed. 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. Metric decimal quantity of medication that would be dispensed for a full quantity.