The resubmitted request must be completed in the same manner as an original reconsideration request. 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. 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 639 0 obj <> endobj 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (402-D2) occur on the same day. 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. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. 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. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Brand Drug Dispensed as a Generic, Substitution Not Allowed - Brand Drug Mandated by Law, Substitution Allowed - Generic Drug Not Available in Marketplace. Metric decimal quantity of medication that would be dispensed for a full quantity. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current. Required if this value is used to arrive at the final reimbursement. DESI drugs and any drug if by its generic makeup and route of administration, it is identical, related, or similar to a less than effective drug identified by the FDA, Drugs classified by the U.S.D.H.H.S. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. Required if Reason for Service Code (439-E4) is used. Prescription cough and cold products may be approved with prior authorization for an acute condition for Dual Eligible (Medicare-Medicaid) members. A 7.5 percent tolerance is allowed between fills for Synagis. Required on all COB claims with Other Coverage Code of 2. COVID-19 early refill overrides are not available for mail-order pharmacies. 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. Required when needed to provide a support telephone number of the other payer to the receiver. Cost-sharing for members must not exceed 5% of their monthly household income. Applicable co-pay is automatically deducted from the provider's payment during claims processing. 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. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. 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. Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. 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. Confirm and document in writing the disposition 0 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. The "Dispense as Written (DAW) Override Codes" table describes the valid scenarios allowable per DAW code. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. The provider creates interactive claims one at a time and transmits them by toll-free telephone through a switch company to the pharmacy benefit manager. Required if identification of the Other Payer Date is necessary for claim/encounter adjudication. The following NCPDP fields below will be required on 340B transactions. 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 following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Required if necessary as component of Gross Amount Due. The following claims can be submitted on paper and processed for payment: Providers can submit only one claim per submission on the PCF, however, compound claims can be submitted. Required for this program when the Other Coverage Code (308-C8) of "3" is used. 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 These values are for covered outpatient drugs. If there is more than a single payer, a D.0 electronic transaction must be submitted. Claims that do not result in the Health First Colorado program authorizing reimbursement for services rendered may be resubmitted. 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 Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). 523-FN Sent if reversal results in generation of pricing detail. Effective 10/22/2021, Corrected formatting error; replaced "" with numeric "0", Added Real Time Prior Authorization via EHR to PAR Process, Updated to reflect billing changes to family planning and family planning-related services, Updated family planning-related section for clarity, Added primary insurance clarification to PAR Process and max day supply clarification to Dispensing Requirements, Added record maintenance requirements under Counseling, Retention of Records, and Signature Requirements, Removed requirement for providers to obtain a new override each fill for TPL/COB prior authorizations, Updated qualifier codes accepted in COB/ Other Payments under Claim Billing, Proposed rendering provider (if identified on the PAR), Non-preferred agents subject to the Preferred Drug List (PDL), Preferred agents with clinical criteria attached to the medication and all non-preferred agents subject to the Preferred Drug List (PDL) Over-the-counter (OTC) drugs that are not a regular Health First Colorado program benefit, Intravenous (IV) solutions with clinical criteria attached to the medication, Total Parenteral Nutrition (TPN) therapy and drugs, Significance of impact on the health of the Health First Colorado program population, Required monitoring of prescribing protocols to protect both the long-term efficacy of the drug and the public health, Potential for, or a history of, drug diversion and other illegal utilization, Appearance of the Health First Colorado program usage in amounts inconsistent with non- medical assistance program usage patterns, after adjusting for population characteristics, Clinical safety and efficacy compared to other drugs in that class of medications, Availability of more cost-effective comparable alternatives, Procedures where inappropriate utilization has been reported in medical literature, Performing auditing services with constant review on drug utilization. Required if Basis of Cost Determination (432-DN) is submitted on billing. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). If a pharmacy is made aware of eligibility after 120 days from the date of service, the pharmacy may submit the claims electronically by obtaining a PAR from the Pharmacy Support Center, or by paper using a pharmacy claim form. 10 = Amount Attributed to Provider Network Selection (133-UJ) Additionally, all providers entering 340B claims must be registered and active with HRSA. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual. 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. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. Required when other insurance information is available for coordination of benefits. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. 06 = Patient Pay Amount (505-F5) 0 523-FN 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. 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. ), SMAC, WAC, or AAC. 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. : 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 Patient Pay Amount (505-F5) includes co-pay as patient financial responsibility. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. More information may be obtained in Appendix P in the Billing Manuals section of the Department's website. Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. The offer to counsel shall be face-to-face communication whenever practical or by telephone. Required when needed to provide a support telephone number. 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. For DAW 8-generic not available in marketplace or DAW 9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Patient Requested Product Dispensed. Required when the Other Payer Reject Code (472-6E) is used. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER, ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Each PA may be extended one time for 90 days. 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. 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. Enter the ingredient drug cost for each product used in making the compound. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional The physician is of an opinion that a transition to the generic equivalent of a brand-name drug would be unacceptably disruptive to the patient's stabilized drug regimen and criteria is met for medication. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Generic Drug Not in Stock, 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. The total service area consists of all properties that are specifically and specially benefited. 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. Required for partial fills. 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. 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. We anticipate that our pricing file updates will be completed no later than February 1, 2021. 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 Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. Required when other coverage is known, which is after the Date of Service submitted. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. Pharmacies should continue to rebill until a final resolution has been reached. Provided for informational purposes only. Required when Approved Message Code (548-6F) is used. Required for partial fills. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. 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. 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 Required when needed per trading partner agreement. If reversal is for multi-ingredient prescription, the value must be 00. Imp Guide: Required, if known, when patient has Medicaid coverage. 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. Amount expressed in metric decimal units of the product included in the compound. If the medication has been determined to be family planning or family planning-related, it should be documented in the prescription record. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. For non-scheduled drugs, 75 percent of the days' supply of the last fill must lapse before a drug can be filled again. 03 =Amount Attributed to Sales Tax (523-FN) Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. Required when additional text is needed for clarification or detail. Required if Other Payer Amount Paid (431-Dv) is used. Required when Basis of Cost Determination (432-DN) is submitted on billing. 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. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care.
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basis of reimbursement determination codes