basis of reimbursement determination codes

Required to identify the actual group that was used when multiple group coverage exist. Pharmacies are expected to keep records indicating when member counseling was not or could not be provided. 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. Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. Required if Other Payer Reject Code (472-6E) is used. PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER, Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. 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. 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. 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. It is used when a sender notifies the receiver of drug utilization, drug evaluations, or information on the appropriate selection to process the claim/encounter. The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a non-preferred formulary product. ADDITIONAL MESSAGE INFORMATION CONTINUITY. Required if Basis of Cost Determination (432-DN) is submitted on billing. If no number is supplied, populate with zeros, Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs), OCC codes 0, 1, 2, 3, and 4 Supported (no co-pay only billing allowed), COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT. Required - Enter total ingredient costs even if claim is for a compound prescription. In addition, some products are excluded from coverage and are listed in the Restricted Products section. The Department does not pay for early refills when needed for a vacation supply. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Required for partial fills. iT|'r4O!JtN!EIVJB yv7kAY:@>1erpFBkz.cDEXPTo|G|r>OkWI/"j1;gT* :k $O{ftLZ>T7h.6k>a'vh?a!>7 s This dollar amount will be provided, when known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount. 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. Required if utilization conflict is detected. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Services cannot be withheld if the member is unable to pay the co-pay. 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 necessary for patient financial responsibility only billing. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. 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. 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. 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. 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 All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. The total service area consists of all properties that are specifically and specially benefited. Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate Program. Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. The Health First Colorado program restricts or excludes coverage for some drug categories. Required if needed by receiver to match the claim that is being reversed. Parenteral Nutrition Products "C" indicates the completion of a partial fill. Required for this program when the Other Coverage Code (308-C8) of "3" is used. Required if needed to identify the transaction. "Required when." This dollar amount will be provided, if known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount. The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. Required if Basis of Cost Determination (432-DN) is submitted on billing. Pharmacies may use the number 8 in Field # 420-DK instead of obtaining a PA for non-covered ingredients to allow the claim to pay for the ingredients that are considered a covered benefit. Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. Please contact the Pharmacy Support Center with questions. 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. 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. 20 = 340B - Indicates that, prior to providing service, the pharmacy has determined the product being billed is purchased pursuant to rights available under Section 340B of the Public Health Act of 1992 including sub-ceiling purchases authorized by Section 340B (a) (10) and those made through the Prime Vendor Program (Section 340B(a)(8)). Required when Additional Message Information (526-FQ) is used. Members within this eligibility category will not be subject to utilization management policies as outlined in the Appendix P, Preferred Drug List (PDL) or Appendix Y. The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication. The use of inaccurate or false information can result in the reversal of claims. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. 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 Confirm and document in writing the disposition The pharmacy benefit manager reviews the claim and immediately returns a status of paid or denied for each transaction to the provider's personal computer. Required when Basis of Cost Determination (432-DN) is submitted on billing. %%EOF 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 Pharmacies should continue to rebill until a final resolution has been reached. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. : 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.. 1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads. 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. If there is more than a single payer, a D.0 electronic transaction must be submitted. 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. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. The following lists the segments and fields in a Claim Billing or Claim Re-bill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Required if identification of the Other Payer Date is necessary for claim/encounter adjudication. Metric decimal quantity of medication that would be dispensed for a full quantity. An emergency is any condition that is life-threatening or requires immediate medical intervention. 523-FN 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 when utilization conflict is detected.

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