If PAR is authorized, claim will pay with DAW1. Nursing facilities must furnish IV equipment for their patients. Required when any other payment fields sent by the sender. Claims that do not result in the Health First Colorado program authorizing reimbursement for services rendered may be resubmitted. No products in the category are Medical Assistance Program benefits. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. 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. Required when needed for receiver claim determination when multiple products are billed. 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 Caremark If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. Cheratussin AC, Virtussin AC). OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT. 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) Required if needed to provide a support telephone number of the other payer to the receiver. Required when Other Amount Paid (565-J4) is used. Maternal, Child and Reproductive Health billing manual web page. BASIS Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). 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. Companion Document To Supplement The NCPDP VERSION Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. 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. Pursuant to 42CFR 455.10(b) and 42CFR 455.440, Health First Colorado will not pay for prescriptions written by unenrolled prescribers. Copies of all forms necessary for submitting claims are also available on the Pharmacy Resources web page of the Department's website. 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. enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. 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 for 340B Claims. Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. No blanks allowed. 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. Required when Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. Some claim submission requirements include timely filing, eligibility requirements, pursuit of third-party resources, and required attachments included. 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. 523-FN Drugs administered in the hospital are part of the hospital fee. The form is one-sided and requires an authorized signature. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. 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 Access to Standards The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. 19 Antivirals Dispensing and Reimbursement Download Standards Membership in NCPDP is required for access to standards. Testing Procedures - Alabama Medicaid 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. =y?@d:qb@6l7YC&)H]zjse/0 m{YSqT;?z~bDG_agiZo8pomle;]Zt QmF8@bt/ &|=SM1LZTr'hxu&0\lcmUFC!BKXrT} 7IFD&t{TagKwRI>T$ wja 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. Indicates that the drug was purchased through the 340B Drug Pricing Program. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. If there is a marketplace shortage for the generic version of the prescribed drug and only the brand-name product is available, claim will pay with DAW 8. 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. Billing Guidance for Pharmacists Professional and Delayed notification to the pharmacy of eligibility. The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website. ", 00 = If claim is a multi-ingredient compound transaction, Required - If claim is for a compound prescription, enter "00.". Reimbursement Effective November 1, 2022, the Department is implementing a list of family planning-related drugs that may be covered pursuant to existing utilization management policies as outlined in the Appendix P, PDL or Appendix Y, if applicable. The Field is mandatory for the Segment in the designated Transaction. Single agent antihistamines and their combination products with a decongestant are not considered to be cough and cold products and are regular Medical Assistance Program benefits. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). Prescription cough and cold products may be approved with prior authorization for an acute condition for Dual Eligible (Medicare-Medicaid) members. The Health First Colorado program restricts or excludes coverage for some drug categories. Signature requirements are temporarily waived for Member Counseling and Proof of Delivery. 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). Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. Required - If claim is for a compound prescription, list total # of units for claim. B. Required if utilization conflict is detected. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. Caremark Drug used for erectile or sexual dysfunction. Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc.