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. 07 = Amount of Co-insurance (572-4U) Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). Members in this eligibility category may receive up to a 12-month supply ofcontraceptiveswith a $0 co-pay. Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. Required if Basis of Cost Determination (432-DN) is submitted on billing. Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. Required if this field could result in contractually agreed upon payment. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. The table below 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. It will contain an estimate of the difference between the cost of the brand drug and the generic drug, when the brand drug is more expensive than the generic. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. This document contains the specifications of six templates: Payer: Please list each transaction supported with the segments, fields and pertinent information on each transaction. Required - If claim is for a compound prescription, list total # of units for claim. Required if this field is reporting a contractually agreed upon payment. One of the other designators, "M", "R" or "RW" will precede it. The total service area consists of all properties that are specifically and specially benefited. Required when a product preference exists that needs to be communicated to the receiver via an ID. Please see the payer sheet grid below for more detailed requirements regarding each field. Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). Required when Other Amount Paid (565-J4) is used. Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. 01 = Amount applied to periodic deductible (517-FH) OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT. Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. The Department does not pay for early refills when needed for a vacation supply. Medication Requiring PAR - Update to Over-the-counter products. Required if needed to match the reversal to the original billing transaction. 0
Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. Please visit the OPR section of the Department's website for more detailed information about enrollment and compliance with the Affordable Care Act. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. If a member has Medicaid as their secondary insurance and their primary insurance covers a medication, but Health First Colorado requires a prior authorization for the medication, the pharmacy or provider may request a prior authorization override by contacting the Magellan Helpdesk at 1-800-424-5725. Required if Reason for Service Code (439-E4) is used. It is used for multi-ingredient prescriptions, when each ingredient is reported. Required when Additional Message Information (526-FQ) is used. Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility. Sent when Other Health Insurance (OHI) is encountered during claim processing. These source documents, in addition to any work papers and records used to create electronic media claims, shall be retained by the provider for seven years and shall be made readily available and produced upon request of the Secretary of the Department of Health and Human Services, the Department, and the Medicaid Fraud Control Unit and their authorized agents. Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. Approval of a PAR does not guarantee payment. Required when Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits, 3 = Other Coverage Billed Claim not Covered. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. 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 only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQW) follows it, and the text of the following message is a continuation of the current. ), SMAC, WAC, or AAC. The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. 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. 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 when Help Desk Phone Number (550-8F) is used. Required when Basis of Cost Determination (432-DN) is submitted on billing. Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). Required when Basis of Cost Determination (432-DN) is submitted on billing. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. 06 = Patient Pay Amount (505-F5) Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. endstream
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Health First Colorado does not provide reimbursement for products by manufacturers that have not signed a rebate agreement unless the Department has made a determination that the availability of the drug is essential, such drug has been given 1-A rating by the Food and Drug Administration (FDA), and prior authorized. 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. Members of these eligibility categories will be subject to utilization management policies as outlined in the Appendix P, PDL or Appendix Y. Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Pursuant to 42CFR 455.10(b) and 42CFR 455.440, Health First Colorado will not pay for prescriptions written by unenrolled prescribers. We anticipate that our pricing file updates will be completed no later than February 1, 2021. For non-scheduled drugs, 75 percent of the days' supply of the last fill must lapse before a drug can be filled again. Q,iDfh|)vCDD&I}nd~S&":@*DcS|]!ph);`s/EyxS5] zVHJ~4]T}+1d'R(3sk0YwIz$[))xB:H U]yno- VN1!Q`d/%a^4\+ feCDX$t]Sd?QT"I/%. 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. Applicable co-pay is automatically deducted from the provider's payment during claims processing. Interactive claim submission must comply with Colorado D.0 Requirements. Required if any other payment fields sent by the sender. 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. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Enrolling in Health First Colorado as an OPR provider: If an OPR prescriber does not wish to enroll with Health First Colorado they must refer their patients to an enrolled prescriber, otherwise claims will deny. DISPENSING FEE CONTRACTED/REIMBURSABLE AMOUNT. 03 = National Drug Code (NDC) - Formatted 11 digits (N). The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a non-preferred formulary product. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Provided for informational purposes only. 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. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. 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. The following NCPDP fields below will be required on 340B transactions. Required for partial fills. "C" indicates the completion of a partial fill. ADDITIONAL MESSAGE INFORMATION CONTINUITY. 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. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. 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 All services to women in the maternity cycle. Required when text is needed for clarification or 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 Patient Pay Amount (505-F5) includes co-pay as patient financial responsibility. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. Required if Previous Date Of Fill (530-FU) is used. Instructions on how to complete the PCF are available in this manual. Required when Patient Pay Amount (505-F5) includes sales tax that is the financial responsibility of the member but is not also included in any of the other fields that add up to Patient Pay Amount. Required when Preferred Product ID (553-AR) is used. Required when a repeating field is in error, to identify repeating field occurrence. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). 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. A generic drug is not therapeutically equivalent to the brand name drug. Figure 4.1.3.a. 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. 1710 0 obj
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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 Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Payer Issued, One transaction for B2 or compound claim, Four allowed for B1 or B3, Code qualifying the 'Service Provider ID' (Field # 201-B1), This will be provided by the provider's software vendor, Assigned when vendor is certified with Magellan Rx Management - If not number is supplied, populate with zeros, UNITED STATES AND CANADIAN PROVINCE POSTAL SERVICE. In determining what drugs should be subject to prior authorization, the following criteria is used: Most brand-name drugs with a generic therapeutic equivalent are not covered by the Health First Colorado program. ), SMAC, WAC, or AAC. * Cough and cold products: Cough and cold products include combinations of narcotic and nonnarcotic cough suppressants, expectorants, and/or decongestants. Parenteral Nutrition Products Required when Benefit Stage Amount (394-MW) is used. 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)). 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. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. 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. Required when Other Amount Claimed Submitted (480-H9) is used. Paper claims may be submitted using a pharmacy claim form. The resubmitted request must be completed in the same manner as an original reconsideration request. Indicates that the drug was purchased through the 340B Drug Pricing Program. It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. The total service area consists of all properties that are specifically and specially benefited. The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. Required when Compound Ingredient Modifier Code (363-2H) is sent. For the expanded income group, if the prescriber confirms that the drug was not prescribed in relation to a family planning visit, then it will be denied. 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. Required for partial fills. 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. 81J
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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. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Required when Quantity of Previous Fill (531-FV) is used. 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. 523-FN : 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 when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION. 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. Timely filing for electronic and paper claim submission is 120 days from the date of service. 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 Required if this value is used to arrive at the final reimbursement. 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) All electronic claims must be submitted through a pharmacy switch vendor. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. Required when necessary to identify the Patient's portion of the Sales Tax. Health First Colorado is the payer of last resort. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. ADDITIONAL MESSAGE INFORMATION CONTINUITY. The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. 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. Required when needed to supply additional information for the utilization conflict. Required when a product preference exists that either cannot be communicated by the Preferred Product ID (553-AR) or to clarify the Preferred Product ID (553-AR). 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. Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Flat Sales Tax Amount Paid (558-AW) is greater than zero (0). Required if needed to provide a support telephone number to the receiver. Services cannot be withheld if the member is unable to pay the co-pay. Providers must submit accurate information. Sent when DUR intervention is encountered during claim adjudication. If reversal is for multi-ingredient prescription, the value must be 00. 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. 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. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements. 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 Previous Date Of Fill (530-FU) is used. Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. CMS began releasing RVU information in December 2020. The table below 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. Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. "Required When." Exception for DEA Schedule II medications:Initial Incremental fills are allowed for DEA Schedule II prescription drugs dispensed to ALL members. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. Does not obligate you to see Health First Colorado members. Required on all COB claims with Other Coverage Code of 2. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. Product may require PAR based on brand-name coverage. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. Effective February 25, 2017, pharmacies must code their systems using the D.0 Payer Sheets provided below when submitting pharmacy POS transactions to the Health First Colorado program for payment. 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. 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 if Basis of Cost Determination (432-DN) is submitted on billing. Enter the ingredient drug cost for each product used in making the compound. For TXIX, if the prescriber confirms that the drug was not prescribed in relation to a family planning visit, then the pharmacy should remove the 6-Family Plan from the claim so that the claim can adjudicate accordingly. 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.
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