basis of reimbursement determination codes

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.) 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 Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. Values other than 0, 1, 08 and 09 will deny. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). 1710 0 obj <> endobj This pharmacy billing manual explains many of the Colorado Department of Health Care Policy & Financing's (the Department) policies regarding billing, provider responsibilities, and program benefits. =y?@d:qb@6l7YC&)H]zjse/0 m{YSqT;?z~bDG_agiZo8pomle;]Zt QmF8@bt/ &|=SM1LZTr'hxu&0\lcmUFC!BKXrT} 7IFD&t{TagKwRI>T$ wja 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. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL ADDITIONAL MESSAGE INFORMATION CONTINUITY. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. Required when Quantity of Previous Fill (531-FV) is used. The use of inaccurate or false information can result in the reversal of claims. Required when Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. %%EOF Effective November 1, 2022, the Department is implementing a list of family planning-related drugs that may be covered pursuant to existing utilization management policies as outlined in the Appendix P, PDL or Appendix Y, if applicable. 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 Note: Fields that are not used in the Claim Billing/Claim Re-bill transactions and those that do not have qualified requirements (.i.e., not used) for this payer are excluded from the template. 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. CMS began releasing RVU information in December 2020. CMS began releasing RVU information in December 2020. Required if needed to provide a support telephone number to the receiver. For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). 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 when Other Amount Claimed Submitted Qualifier (479-H8) 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 If the appropriate numbers of days have not lapsed, the claim will be denied as a refill-too-soon unless there has been a change in the dosing. WebExamples of Reimbursable Basis in a sentence. 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. Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. The maternity cycle is the time period during the pregnancy and 365days' post-partum. 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. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. 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 if Previous Date of Fill (530-FU) is used. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. Pharmacies can submit these claims electronically or by paper. Required on all COB claims with Other Coverage Code of 2. 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 Other Amount Claimed Submitted (480-H9) is greater than zero (0). Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Please refer to the specific rules and requirements regarding electronic and paper claims below. Pharmacies may submit claims electronically by obtaining a PAR from thePharmacy Support Center. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Required when needed to supply additional information for the utilization conflict. B. "C" indicates the completion of a partial fill. 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. Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. If reversal is for multi-ingredient prescription, the value must be 00. 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). Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. 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. 1 = Proof of eligibility unknown or unavailable. If a Medicaid member enters or leaves a nursing facility, the member may require a refill-too-soon override in order to receive his or her drugs. 522-fm basis of reimbursement determination r 523-fn amount attributed to sales tax r 512-fc accumulated deductible amount r 513-fd remaining deductible amount r 514-fe remaining benefit amount r 517-fh amount applied to periodic deductible r 518-fi amount of copay r 52-fk amount exceeding periodic WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required if necessary as component of Gross Amount Due. Required if Basis of Cost Determination (432-DN) is submitted on billing. 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. Date of service for the Associated Prescription/Service Reference Number (456-EN). Required when Basis of Cost Determination (432-DN) is submitted on billing. Required when a repeating field is in error, to identify repeating field occurrence. Required when Basis of Cost Determination (432-DN) is submitted on billing. DISPENSING FEE CONTRACTED/REIMBURSABLE AMOUNT. 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 WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). If the claim is denied, pharmacy benefit manager will send one or more denial reason(s) that identify the problem(s). 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. Indicates that the drug was purchased through the 340B Drug Pricing Program. IV equipment (for example, Venopaks dispensed without the IV solutions). Caremark RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Delayed notification to the pharmacy of eligibility. The table below Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Pharmacies are expected to keep records indicating when member counseling was not or could not be provided. When a pharmacy has exhausted all authorized rebilling procedures and has not been paid for a claim, the pharmacy may submit a Request for Reconsideration to the pharmacy benefit manager. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately. We anticipate that our pricing file updates will be completed no later than February 1, 2021. Required when needed per trading partner agreement. Billing Guidance for Pharmacists Professional and 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. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET 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. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). 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. 522-fm basis of reimbursement determination r 523-fn amount attributed to sales tax r 512-fc accumulated deductible amount r 513-fd remaining deductible amount r 514-fe remaining benefit amount r 517-fh amount applied to periodic deductible r 518-fi amount of copay r 52-fk amount exceeding periodic ADDITIONAL MESSAGE INFORMATION CONTINUITY. Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. Required if a repeating field is in error, to identify repeating field occurrence. 0 If the reconsideration is denied, the final option is to appeal the reconsideration. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. WebExamples of Reimbursable Basis in a sentence. Required when Compound Ingredient Modifier Code (363-2H) is sent. 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. Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. Sent when DUR intervention is encountered during claim processing. Required when other insurance information is available for coordination of benefits. An additional request for reconsideration may be submitted within 60 days of the reconsideration denial if information can be corrected or if additional supporting information is available. Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. 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 when Basis of Cost Determination (432-DN) is submitted on billing. Drugs administered in a dialysis unit are part of the dialysis fee or billed on a professional claim. Unless otherwise communicated in the PDL or Appendix P, maintenance medications may be filled for up to a 100-day supply, and non-maintenance medications may be filled for up to a 30-day supply. 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). This field is required when the plan is a participant in a Medicare Part D program that requires reporting of benefit stage specific financial amounts. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. If the medication has been determined to be family planning or family planning- related, it should be documented in the prescription record. Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). 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. 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 the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG. BASIS Parenteral Nutrition Products The Field is mandatory for the Segment in the designated Transaction. Required when specified in trading partner agreement. Required for partial fills. The table below Approval of a PAR does not guarantee payment. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. Cost-sharing for members must not exceed 5% of their monthly household income. 639 0 obj <> endobj 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. The Department does not pay for early refills when needed for a vacation supply. We anticipate that our pricing file updates will be completed no later than February 1, 2021. NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. Pharmacy Figure 4.1.3.a. 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. The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 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. 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) 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. 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 Coordination of Benefits/Other Payments Count, Required if Other Payer ID (Field # 340-7C) is used, Required if identification of the Other Payer Date is necessary for claim/encounter adjudication, CCYYMMDD. United States Health Information Knowledgebase If the original fills for these claims have no authorized refills a new RX number is required. Reimbursable Basis Definition SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). Medication Requiring PAR - Update to Over-the-counter products. Maternal, Child and Reproductive Health billing manual web page. Companion Document To Supplement The NCPDP VERSION If there is more than a single payer, a D.0 electronic transaction must be submitted. 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. One of the other designators, "M", "R" or "RW" will precede it. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL Testing Procedures - Alabama Medicaid The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication. Required for partial fills. Effective 10/22/2021, Updated policy for Quantity Limit overrides in COVID-19 section. 19 Antivirals Dispensing and Reimbursement Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. 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. Required when necessary to identify the Plan's portion of the Sales Tax. Required when Reason For Service Code (439-E4) is used. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). Required when Help Desk Phone Number (550-8F) is used. Access to Standards The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements. The offer to counsel shall be face-to-face communication whenever practical or by telephone. BASIS

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basis of reimbursement determination codes

basis of reimbursement determination codes