Required if Reason for Service Code (439-E4) is used. Required if necessary as component of Gross Amount Due. The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. The Health First Colorado program does not pay a compounding fee. : 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.. 01 = Amount Applied to Periodic Deductible (517-FH), 02 = Amount Attributed to ProductSelection/Brand Drug (134-UK), 03 = Amount Attributed to Sales Tax(523-FN), 04 = Amount Exceeding Periodic Benefit Maximum (520-FK), 06 = Patient Pay Amount (Deductible) (505-F5), 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection(135-UM), 10 = Amount Attributed to Provider Network Selection (133-UJ), 11 = Amount Attributed to Product Selection/Brand Non-Preferred FormularySelection(136-UN), 12 = Amount Attributed to Coverage Gap (137-UP), 13 = Amount Attributed to Processor Fee (571-NZ), MA = Medication Administration - use for vaccine. 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. Required when Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (402-D2) occur on the same day. Additionally, all providers entering 340B claims must be registered and active with HRSA. Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required.". Effective 10/22/2021, Updated policy for Quantity Limit overrides in COVID-19 section. 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with a Covered Outpatient Drug (COD) status equal to DESI - 5 (LTE/IRS drug for all indications or DESI 6 LTE/IRS drug withdrawn from market)].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 needed to provide a support telephone number of the other payer to the receiver. PARs are reviewed by the Department or the pharmacy benefit manager. Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. 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 Pharmacies must complete third-party information on the PCF and submit documentation from the third-party payer of payment or lack of payment. 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. Sent when claim adjudication outcome requires subsequent PA number for payment. The following NCPDP fields below will be required on 340B transactions. Required when other insurance information is available for coordination of benefits. Required when Additional Message Information (526-FQ) is used. Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate Program. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. OTHER PAYER - PATIENT RESPONSIBILITY AMOUNT COUNT, Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used, OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFER, Required if Other Payer-Patient Responsibility Amount (352-NQ) is used352-NQ. Required when Basis of Cost Determination (432-DN) is submitted on billing. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. 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 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Required when needed for receiver claim determination when multiple products are billed. : 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.. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. Express Scripts Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. All pharmacy PARs must be telephoned, faxed, or submitted via Real Time Prior Authorization via EHR, by the prescribing physician or physician's agent to the Pharmacy Benefit Manager Support Center. 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. Required when text is needed for clarification or detail. 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 Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. A generic drug is not therapeutically equivalent to the brand name drug. Download Standards Membership in NCPDP is required for access to standards. 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 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 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. Required when its value has an effect on the Gross Amount Due (430-DU) calculation. No products in the category are Medical Assistance Program benefits. Providers must submit accurate information. All electronic claims must be submitted through a pharmacy switch vendor. %PDF-1.6 % Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. The "Dispense as Written (DAW) Override Codes" table describes the valid scenarios allowable per DAW code. 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. Required on all COB claims with Other Coverage Code of 3. 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 19 Antivirals Dispensing and Reimbursement Applicable co-pay is automatically deducted from the provider's payment during claims processing. 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 Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand non-preferred formulary product. 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. The pharmacy benefit manager processes both electronic and paper claims and provides claim, provider, eligibility, and PAR interfaces with the Medicaid Management Information System (MMIS). 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) 340B Information Exchange Reference Guide - NCPDP If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. 19 Antivirals Dispensing and Reimbursement Required when there is payment from another source. Required if Basis of Cost Determination (432-DN) is submitted on billing. Required if needed to supply additional information for the utilization conflict. United States Health Information Knowledgebase %%EOF WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits, 3 = Other Coverage Billed Claim not Covered. Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. 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. A member has tried the generic equivalent but is unable to continue treatment on the generic drug and criteria is met for medication. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Required if Other Payer patient Responsibility Amount (352-NQ) is submitted. Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim. "Required when." 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
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