basis of reimbursement determination codes

"Required When." 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. Please contact the Pharmacy Support Center with questions. The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. 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. 340B Information Exchange Reference Guide - NCPDP Instructions on how to complete the PCF are available in this manual. Reversal Window (If transaction is billed today, what is the, Required when needed to match the reversal to the original billing transaction. The total service area consists of all properties that are specifically and specially benefited. Required when necessary to identify the Patient's portion of the Sales Tax. Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. 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. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). 81J _FLy4AyGP(O The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. Sent when DUR intervention is encountered during claim processing. Date of service for the Associated Prescription/Service Reference Number (456-EN). 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. Members within this eligibility category are only eligible to receive family planning and family planning-related medication. No blanks allowed. Figure 4.1.3.a. Representation by an attorney is usually required at administrative hearings. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION. Values other than 0, 1, 08 and 09 will deny. A pharmacy should utilize field 461-EU on a pharmacy claim to indicate 6-Family Plan to receive a $0 co-pay on family planning related medications. An optional data element means that the user should be prompted for the field but does not have to enter a value. PB 18-08 340B Claim Submission Requirements and 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. In no case, shall prescriptions be kept in will-call status for more than 14 days. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. 05 = Amount of Co-pay (518-FI) Required when the Other Payer Reject Code (472-6E) is used. Indicates that the drug was purchased through the 340B Drug Pricing Program. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Values other than 0, 1, 08 and 09 will deny. Reimbursement 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. Parenteral Nutrition Products If there is more than a single payer, a D.0 electronic transaction must be submitted. Required if needed by receiver to match the claim that is being reversed. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Express Scripts The total service area consists of all properties that are specifically and specially benefited. 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. All claims for incremental and subsequent fills require valid values in the following fields: Please note: if a pharmacy submits a claim for a non-Schedule II medication and includes a value for quantity prescribed, it must be a valid value. Basis of Cost Determination = This is not a required field on the claim, but 05 (Acquisition) or 08 (340B/Disproportionate Share Pricing/Public Health Service) will be accepted if submitted on the claim. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 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 - 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. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. Access to Standards Prior Authorization Request (PAR) Process, Guidelines Used by the Department for Determining PAR Criteria, Incremental Fills and/or Prescription Splitting, Lost/Stolen/Damaged/Vacation Prescriptions, Temporary COVID-19 Policy and Billing Changes, Medication Prior Authorization Deferments, EUA COVID-19 Antivirals Claim Requirements, Ordering, Prescribing or Referring (OPR) Providers, Delayed Notification to the Pharmacy of Eligibility, Instructions for Completing the Pharmacy Claim Form, Response Claim Billing/Claim Rebill Payer Sheet Template, Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response, Claim Billing/Claim Rebill PAID (or Duplicate of PAID) Response, Claim Billing/Claim Rebill Accepted/Rejected Response, Claim Billing/Claim Rebill Rejected/Rejected Response, NCPDP Version D.0 Claim Reversal Template, Request Claim Reversal Payer Sheet Template, Response Claim Reversal Payer Sheet Template, Claim Reversal Accepted/Approved Response, Claim Reversal Accepted/Rejected Response, Claim Reversal Rejected/Rejected Response, Pharmacy Prior Authorization Policies section. Provided for informational purposes only. Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill). Required if needed to provide a support telephone number of the other payer to the receiver. 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. "P" indicates the quantity dispensed is a partial fill. Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). 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. EY Required when there is payment from another source. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). 1 = Proof of eligibility unknown or unavailable. 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 Required when Other Amount Claimed Submitted (480-H9) is used. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). 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 In addition, some products are excluded from coverage and are listed in the Restricted Products section. The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication. The use of inaccurate or false information can result in the reversal of claims. For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Reimbursement Rates for 2021 Procedure Codes Providers should also consult the Code of Colorado Regulations (10 C.C.R. 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. 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. Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. Paper claims may be submitted using a pharmacy claim form. 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. 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. 19 Antivirals Dispensing and Reimbursement Required if Basis of Cost Determination (432-DN) is submitted on billing. 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. INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT. Parenteral Nutrition Products 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. Reimbursable Basis Definition PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. Payer Specifications D.0 : 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.. Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual. Companion Document To Supplement The NCPDP VERSION 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. "C" indicates the completion of a partial fill. Dispensing (Incentive) Fee = Standard dispense fee based on a pharmacys total annual prescription volume will still apply. Enter the ingredient drug cost for each product used in making the compound. 340B Information Exchange Reference Guide - NCPDP 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 Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. Reimbursement Rates for 2021 Procedure Codes Required when Basis of Cost Determination (432-DN) is submitted on billing. If PAR is authorized, claim will pay with DAW1. Additionally, all providers entering 340B claims must be registered and active with HRSA. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. 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. If reversal is for multi-ingredient prescription, the value must be 00. Required for partial fills. 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. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Required for this program when the Other Coverage Code (308-C8) of "3" is used. To find out if a medication is a covered pharmacy benefit, refer to the Appendix P and/or the Preferred Drug List (PDL) located on the Pharmacy Resources web page. For DAW 8-generic not available in marketplace or DAW 9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual", Allowed by Prescriber but Plan Requests Brand. Download Standards Membership in NCPDP is required for access to standards. For more information related to physician administered drugs and billing for this population, please visit the Physician-Administered-Drug (PAD) Billing Manual. Providers must submit accurate information. Required for partial fills. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. 01 = Amount applied to periodic deductible (517-FH) A PAR is only necessary if an ingredient in the compound is subject to prior authorization. Reimbursement Basis Definition 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. The field is mandatory for the Segment in the designated Transaction. Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. Other Payer Bank Information Number (BIN). For DEA Schedule 2 through 5 drugs, 85 percent of the days' supply of the last fill must lapse before a drug can be filled again. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER. Required for partial fills. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand non-preferred formulary product. Required when Approved Message Code (548-6F) is used. Required if other payer has approved payment for some/all of the billing. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). For all other information as it relates to family planning benefits, please visit the Maternal, Child and Reproductive Health billing manual web page. 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). 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. 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. 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 on all COB claims with Other Coverage Code of 2. The maternity cycle is the time period during the pregnancy and 365days' post-partum. Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. Pharmacies should retrieve their Remittance Advice (RA) or X12N 835 through the Provider Web Portal. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. 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. Maternal, Child and Reproductive Health billing manual web page. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. 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. hb```+@(1Q(b!V R;Wyjn~u~kw~}CI @B 8F8CEVR,r@Zk0226H;)maVf\p@j053s0OIk5v X u cs. endstream endobj startxref Access to Standards RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET 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)]. Required if Other Payer ID (340-7C) is used. The claim may be a multi-line compound claim. Cost-sharing for members must not exceed 5% of their monthly household income. 06 = Patient Pay Amount (505-F5) Claims that cannot be submitted through the vendor must be submitted on paper. Required for the partial fill or the completion fill of a prescription. %%EOF Health First Colorado is the payer of last resort. =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 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 WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. Restricted products by participating companies are covered as follows: The following are not benefits of the Health First Colorado program: The following are not pharmacy benefits of the Health First Colorado program: The pharmacy benefit manager provides a Pharmacy Support Center to handle clinical, technical, and member calls. Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. 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). ADDITIONAL MESSAGE INFORMATION CONTINUITY. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. For non-mail order transactions, there is a maximum 20-day accumulation allowed every rolling 180 days. The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 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. The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication. 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. Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. If a pharmacy disagrees with the final decision of the pharmacy benefit manager, the pharmacy may file an appeal with the Office of Administrative Courts. WebExamples of Reimbursable Basis in a sentence. Provided for informational purposes only. 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. May be used for cases where Health First Colorado's drug list designates both a brand drug and its generic equivalent as non-preferred products and also designates that the non-preferred brand product is favored for coverage over the equivalent non-preferred generic. Required for partial fills. Pharmacy Testing Procedures - Alabama Medicaid These records must be maintained for at least seven (7) years. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. B. Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. Drug used for erectile or sexual dysfunction. United States Health Information Knowledgebase Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y.
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