basis of reimbursement determination codes

RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET Reimbursement Rates for 2021 Procedure Codes 661 0 obj <>/Filter/FlateDecode/ID[<62EB3A7657CA4643BE855C13B68E8087>]/Index[639 39]/Info 638 0 R/Length 107/Prev 799058/Root 640 0 R/Size 678/Type/XRef/W[1 3 1]>>stream Drugs administered in a dialysis unit are part of the dialysis fee or billed on a professional claim. ), SMAC, WAC, or AAC. All services to women in the maternity cycle. Appeals may be sent to: With few exceptions, providers are required to submit claims electronically. It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. Durable Medical Equipment (DME), these must be billed as a medical benefit on a professional claim. 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 if other insurance information is available for coordination of benefits. 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)). Parenteral Nutrition Products 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 when Other Amount Paid (565-J4) is used. Required if Other Payer patient Responsibility Amount (352-NQ) is submitted. We anticipate that our pricing file updates will be completed no later than February 1, 2021. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT, Required for all COB claims with Other Coverage Code of 2 or 4. More information may be obtained in Appendix P in the Billing Manuals section of the Department's website. 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 if necessary as component of Gross Amount Due. Please see the payer sheet grid below for more detailed requirements regarding each field. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. Nursing facilities must furnish IV equipment for their patients. If the claim is denied, pharmacy benefit manager will send one or more denial reason(s) that identify the problem(s). 677 0 obj <>stream 1 = Proof of eligibility unknown or unavailable. A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). 639 0 obj <> endobj Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. Providers must submit accurate information. If a pharmacy is made aware of eligibility after 120 days from the date of service, the pharmacy may submit the claims electronically by obtaining a PAR from the Pharmacy Support Center, or by paper using a pharmacy claim form. Required if needed by receiver to match the claim that is being reversed. Providers must follow the instructions below and may only submit one (prescription) per claim. Sent when claim adjudication outcome requires subsequent PA number for payment. Required when text is needed for clarification or detail. The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website. Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately. Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. This will allow the pharmacist to determine if the medication was prescribed in relation to a family planning visit (e.g., tobacco cessation, UTI and STI/STD medications). Indicates that the drug was purchased through the 340B Drug Pricing Program. A generic drug is not therapeutically equivalent to the brand name drug. Required when additional text is needed for clarification or detail. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). Required when Other Payer ID (340-7C) is used. %%EOF 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. Required if needed to provide a support telephone number to the receiver. Required if Reason for Service Code (439-E4) is used. Required for the partial fill or the completion fill of a prescription. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. In no case, shall prescriptions be kept in will-call status for more than 14 days. COMPOUND INGREDIENT BASIS OF COST DETERMINATION. Required for 340B 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. Pharmacies may call the Pharmacy Support Center to request a quantity limit override 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. : 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.. Health First Colorado is the payer of last resort. The following NCPDP fields below will be required on 340B transactions. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 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. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. 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 needed for reversals when multiple fills of the same Prescription/Service Reference Number (402-D2) occur on the same day. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Required when the Other Payer Reject Code (472-6E) is used. Required on all COB claims with Other Coverage Code of 3. 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) The use of inaccurate or false information can result in the reversal of claims. CMS began releasing RVU information in December 2020. Instructions on how to complete the PCF are available in this manual. If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax. Only members have the right to appeal a PAR decision. 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 if needed to match the reversal to the original billing transaction. Colorado Pharmacy supports up to 25 ingredients. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. These will be handled on a case-by-case basis by the Pharmacy Support Center if requested by a Health First Colorado healthcare professional (i.e. Required when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. Provided for informational purposes only. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). 340B Information Exchange Reference Guide - NCPDP If PAR is authorized, claim will pay with DAW1. Required if this field is reporting a contractually agreed upon payment. 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. Reimbursement endstream endobj startxref Required if text is needed for clarification or detail. These values are for covered outpatient drugs. B. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Required - Pharmacy's Usual and Customary Charge, Required if Other Cov Code equals 2, 3, or 4, Other Payer Patient Responsibility $ Qualifier, Required when claim is for a compound prescription, 8 = Process Compound Claim for Approved Ingredients, Conditional - Needed to process claim for approved ingredients when claim is for a compound prescription, Required when the claim is for a compound prescription. Member Contact Center1-800-221-3943/State Relay: 711. 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 Single agent antihistamines and their combination products with a decongestant are not considered to be cough and cold products and are regular Medical Assistance Program benefits. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. 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 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. 523-FN Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. Required if identification of the Other Payer Date is necessary for claim/encounter adjudication. Required if any other payment fields sent by the sender. 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. Required if Basis of Cost Determination (432-DN) is submitted on billing. The Health First Colorado program does not pay a compounding fee. hbbd```b``} DL`D^A$KT`H2nfA H/# -~$G@3@"@*Z? A PAR is only necessary if an ingredient in the compound is subject to prior authorization. Companion Document To Supplement The NCPDP VERSION 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. Required when needed to provide a support telephone number of the other payer to the receiver. The maternity cycle is the time period during the pregnancy and 365days' post-partum. 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. WebExamples of Reimbursable Basis in a sentence. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. Required when its value has an effect on the Gross Amount Due (430-DU) calculation. Required when Benefit Stage Amount (394-MW) 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. Confirm and document in writing the disposition ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). 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. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Paper claims may be submitted using a pharmacy claim form. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. 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. Required when a product preference exists that needs to be communicated to the receiver via an ID. 04 = Amount Exceeding Periodic Benefit Maximum (520-FK) Required - If claim is for a compound prescription, list total # of units for claim. 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. If the medication has been determined to be family planning or family planning-related, it should be documented in the prescription record. Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. Express Scripts DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Required when necessary for patient financial responsibility only billing. 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. iT|'r4O!JtN!EIVJB yv7kAY:@>1erpFBkz.cDEXPTo|G|r>OkWI/"j1;gT* :k $O{ftLZ>T7h.6k>a'vh?a!>7 s Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. Required if Previous Date Of Fill (530-FU) is used. Please refer to the specific rules and requirements regarding electronic and paper claims below. endstream endobj startxref Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Access to Standards 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. 1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads. Testing Procedures - Alabama Medicaid Billing Guidance for Pharmacists Professional and All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) Download Standards Membership in NCPDP is required for access to standards. 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. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Prescriptions generally cannot be dispensed in quantities less than the physician ordered unless the quantity ordered is more than a 100-day supply for maintenance medications or more than a 30-day supply for non-maintenance medications. To find out if a medication is a covered pharmacy benefit, refer to the Appendix P and/or the Preferred Drug List (PDL) located on the Pharmacy Resources web page. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL Required if Patient Pay Amount (505-F5) includes deductible. Required to identify the actual group that was used when multiple group coverage exist. "P" indicates the quantity dispensed is a partial fill. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. 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. When timely filing expires due to delays in receiving third-party payment or denial documentation, the pharmacy benefit manager is authorized to consider the claim as timely if received within 60 days from the date of the third-party payment or denial or within 365 days of the date of service, whichever occurs first. One of the other designators, "M", "R" or "RW" will precede it. Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc. Prescription cough and cold products for all ages will not require prior authorization for Health First Colorado members. 81J _FLy4AyGP(O Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. Exception for DEA Schedule II medications:Initial Incremental fills are allowed for DEA Schedule II prescription drugs dispensed to ALL members. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). Required when there is payment from another source. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. The procedure to request a PAR and the medications that require a PAR are outlined in Appendix P - Pharmacy Benefit Prior Authorization Procedures and Criterialocated in the Pharmacy Prior Authorization Policies section of the Department's website. 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. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER. 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 when this value is used to arrive at the final reimbursement. The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 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. Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. Required when Quantity of Previous Fill (531-FV) is used. Confirm and document in writing the disposition Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORMULARY SELECTION. Required if the identification to be used in future transactions is different than what was submitted on the request. Pharmacies should continue to rebill until a final resolution has been reached. Figure 4.1.3.a. 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. 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. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational 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. Download Standards Membership in NCPDP is required for access to standards. Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required.". Sent when Other Health Insurance (OHI) is encountered during claim processing. 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 Claims that cannot be submitted through the vendor must be submitted on paper. Reimbursement Basis Definition Required when needed to communicate DUR information. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. These records must be maintained for at least seven (7) years. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. Providers can collect co-pay from the member at the time of service or establish other payment methods. Required when Additional Message Information (526-FQ) is used. 12 = Amount Attributed to Coverage Gap (137-UP) Companion Document To Supplement The NCPDP VERSION All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Pharmacy Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. Health & Safety in the Home, Workplace & Outdoors, Clinical Guidelines, Standards & Quality of Care, All Health Care Professionals & Patient Safety, Elderly Pharmaceutical Insurance Coverage (EPIC) Program, Payer Specifications D.0 is also available in Portable Document Format, Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template, Response Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template, Request Claim Reversal (B2) Payer Sheet Template, Response Claim Reversal Accepted/Approved (B2) Payer Sheet Template, Response Claim Reversal Accepted/Rejected (B2) Payer Sheet Template, Response Claim Reversal Rejected/Rejected (B2) Payer Sheet Template, James V. McDonald, M.D., M.P.H., Acting Commissioner, Multisystem Inflammatory Syndrome in Children (MIS-C), Addressing the Opioid Epidemic in New York State, Health Care and Mental Hygiene Worker Bonus Program, Maternal Mortality & Disparate Racial Outcomes, Help Increasing the Text Size in Your Web Browser. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. COVID-19 early refill overrides are not available for mail-order pharmacies. The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. Providers should also consult the Code of Colorado Regulations (10 C.C.R. 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 Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing.
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