basis of reimbursement determination codes

Colorado Pharmacy supports up to 25 ingredients. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a cost share differential due to the selection of one pharmacy over another. DISPENSING FEE CONTRACTED/REIMBURSABLE AMOUNT. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. Required when needed to communicate DUR information. Required - Enter total ingredient costs even if claim is for a compound prescription. 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. 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. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Prescription cough and cold products for all ages will not require prior authorization for Health First Colorado members. Required when Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. Representation by an attorney is usually required at administrative hearings. Please contact the Pharmacy Support Center with questions. 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. Metric decimal quantity of medication that would be dispensed for a full quantity. Nursing facilities must furnish IV equipment for their patients. 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) Required when a product preference exists that needs to be communicated to the receiver via an ID. Required if Basis of Cost Determination (432-DN) is submitted on billing. Approval of a PAR does not guarantee payment. 1750 0 obj <>stream PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. 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. Amount expressed in metric decimal units of the product included in the compound. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). 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. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. Please refer to the specific rules and requirements regarding electronic and paper claims below. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Pharmacies should retrieve their Remittance Advice (RA) or X12N 835 through the Provider Web Portal. Note: the pharmacy may call the Pharmacy Support Center to request a zero co-pay 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. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 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. CMS began releasing RVU information in December 2020. Values other than 0, 1, 08 and 09 will deny. 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). 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. 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. Required if utilization conflict is detected. 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. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. Required when the patient's financial responsibility is due to the coverage gap. 13 = Amount Attributed to Processor Fee (571-NZ). The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. If the original fills for these claims have no authorized refills a new RX number is required. COVID-19 early refill overrides are not available for mail-order pharmacies. Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). Required when the Other Payer Reject Code (472-6E) 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. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER. 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. Pharmacies should continue to rebill until a final resolution has been reached. Members that meet their monthly co-pay maximum, or 5% of their monthly household income, will be exempt from co-pay for the remainder of that month. Required if Other Amount Claimed Submitted (480-H9) is greater than zero (0). 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. Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Required if this value is used to arrive at the final reimbursement. This document contains the specifications of six templates: Payer: Please list each transaction supported with the segments, fields and pertinent information on each transaction. The total service area consists of all properties that are specifically and specially benefited. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. Exception for DEA Schedule II medications:Initial Incremental fills are allowed for DEA Schedule II prescription drugs dispensed to ALL members. 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. The total service area consists of all properties that are specifically and specially benefited. Required when Previous Date Of Fill (530-FU) is used. Required when additional text is needed for clarification or detail. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). 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. Notification of PAR approval or denial is sent to each of the following parties: In addition to stating whether the PAR has been approved or denied, a PAR denial notification letter is sent to members. Quantity Prescribed (Field # 460-ET) for ALL DEA Schedule II prescription drugs, regardless of incremental or full-quantity fills, Quantity Intended To Be Dispensed (Field # 344-HF), Days Supply Intended To Be Dispensed (Field # 345-HG). All electronic claims must be submitted through a pharmacy switch vendor. In addition, some products are excluded from coverage and are listed in the Restricted Products section. Required when Benefit Stage Amount (394-MW) is used. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER, ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Local and out-of-state pharmacies may provide mail-order prescriptions for Medicaid members if they are enrolled with the Health First Colorado program and are registered and in good standing with the State Board of Pharmacy. 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 when a repeating field is in error, to identify repeating field occurrence. Required when Quantity of Previous Fill (531-FV) is used. INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT. The "Dispense as Written (DAW) Override Codes" table describes the valid scenarios allowable per DAW code. 12 = Amount Attributed to Coverage Gap (137-UP) Required when the customer is responsible for 100 percent of the prescription payment and when the provider net sale is less than the amount the customer is expected to pay. This value is the prescription number from the first partial fill. Indicates that the drug was purchased through the 340B Drug Pricing Program. For non-mail order transactions, there is a maximum 20-day accumulation allowed every rolling 180 days. Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax. No blanks allowed. Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. Required when Basis of Cost Determination (432-DN) is submitted on billing. Enter the ingredient drug cost for each product used in making the compound. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. Required when Preferred Product ID (553-AR) is used. It is used for multi-ingredient prescriptions, when each ingredient is reported. Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. 523-FN For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). The standard drug ingredient reimbursement methodology applies to the quantity dispensed with each fill. An optional data element means that the user should be prompted for the field but does not have to enter a value. 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. 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. All products in this category are regular Medical Assistance Program benefits. Required if needed to match the reversal to the original billing transaction. If a member calls the call center, the member will be directed to have the pharmacy call for the override. ", 00 = If claim is a multi-ingredient compound transaction, Required - If claim is for a compound prescription, enter "00.". Sent if reversal results in generation of pricing detail. WebExamples of Reimbursable Basis in a sentence. Sent when Other Health Insurance (OHI) is encountered during claims processing. 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. Required only for secondary, tertiary, etc., claims. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. 1710 0 obj <> endobj Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). The use of inaccurate or false information can result in the reversal of claims. Physicians and other practitioners who order, prescribe or refer items or services for Health First Colorado members, but who choose not to submit claims to Health First Colorado, are referred to as OPR providers. Copies of all RAs, electronic claim rejections, and/or correspondence documenting compliance with timely filing and 60-day rule requirements must be submitted with the Request for Reconsideration. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Required when needed for receiver claim determination when multiple products are billed. 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 Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. Required when necessary for plan benefit administration. Required if this field could result in contractually agreed upon payment. Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill). Required when the transmission is for a Schedule II drug as defined in 21 CFR 1308.12 and per CMS-0055-F (Compliance Date 9/21/2020.) Required when Flat Sales Tax Amount Submitted (481-HA) is greater than zero (0) or when Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement. An emergency is any condition that is life-threatening or requires immediate medical intervention. NCPDP Telecommunication Standard Version/Release #: Provider Relations Help Desk Information: NCPDP Telecommunication version 5.1 until TBD. hbbd```b``"`DrVH$0"":``9@n]bLlv #3~ ` +c We anticipate that our pricing file updates will be completed no later than February 1, 2021. Prior authorization requests for some products may be approved based on medical necessity. 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). Required when needed to identify the transaction. endstream endobj 1711 0 obj <>>>/Filter/Standard/Length 128/O(V^TpFH<1b,pdk%{ \rL)/P -1052/R 4/StmF/StdCF/StrF/StdCF/U(Z6r>H8 )/V 4>> endobj 1712 0 obj <>/Metadata 104 0 R/Outlines 447 0 R/PageLayout/OneColumn/Pages 1702 0 R/StructTreeRoot 608 0 R/Type/Catalog>> endobj 1713 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1714 0 obj <>stream It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). 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. Mental illness as defined in C.R.S 10-16-104 (5.5). Required when Other Amount Paid (565-J4) is used. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. Additionally, all providers entering 340B claims must be registered and active with HRSA. Drugs administered in the hospital are part of the hospital fee. Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). Required when Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. Interactive claim submission must comply with Colorado D.0 Requirements. Health First Colorado is temporarily deferring medication prior authorization (PA) requirements for members on all medications for which there is an existing 12-month PA approval in place. If there is more than a single payer, a D.0 electronic transaction must be submitted. 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. 0 Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. Required to identify the actual group that was used when multiple group coverage exist. Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. 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. Required if Additional Message Information (526-FQ) is used. 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) 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. If PAR is authorized, claim will pay with DAW1. Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (402-D2) occur on the same day. The PCF should be submitted to Magellan Rx Management agent at: Below are the completion instructions for the Colorado Pharmacy Claim Form (PCF-2) for Pharmacy Providers. Sent when claim adjudication outcome requires subsequent PA number for payment. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. "Required When." Updated Lost/Stolen/Damaged/Vacation Prescriptions section - police report is no longer required for Stolen Medications, PAR Process: Updated notification letter section, Partial Fills and/or Prescription: Updated partial fill criteria, Updated contact information on page 15, to include Magellan's helpdesk info.

2022 Genesis G70 Headlights, List Of Plantations That Became Prisons, Eggs Taste Different After Covid, Where Is The Cheapest Farmland In Canada, Dr Cornel West Wife Picture, Articles B