basis of reimbursement determination codes

hbbd```b``"`DrVH$0"":``9@n]bLlv #3~ ` +c Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. The use of inaccurate or false information can result in the reversal of claims. 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 Help Desk Phone Number (550-8F) is used. 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 If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. For non-scheduled drugs, 75 percent of the days' supply of the last fill must lapse before a drug can be filled again. 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. 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. Required when needed to supply additional information for the utilization conflict. Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. Required when the patient's financial responsibility is due to the coverage gap. Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. 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. Product may require PAR based on brand-name coverage. Required if Previous Date Of Fill (530-FU) is used. The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. Does not obligate you to see Health First Colorado members. not used) for this payer are excluded from the template. Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). One of the other designators, "M", "R" or "RW" will precede it. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. BNR=Brand Name Required), claim will pay with DAW9. Drug used for erectile or sexual dysfunction. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. Effective 10/22/2021, Updated policy for Quantity Limit overrides in COVID-19 section. 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 when Other Amount Paid (565-J4) is used. If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. An emergency is any condition that is life-threatening or requires immediate medical intervention. Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (402-D2) occur on the same day. The following lists the segments and fields in a Claim Reversal Response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Sent when Other Health Insurance (OHI) is encountered during claims processing. =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 WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION. Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. 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. Required for partial fills. Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. Representation by an attorney is usually required at administrative hearings. If PAR is authorized, claim will pay with DAW1. Maternal, Child and Reproductive Health billing manual web page. Required if Ingredient Cost Paid (506-F6) is greater than zero (0). WebExamples of Reimbursable Basis in a sentence. ), SMAC, WAC, or AAC. 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. Drug list criteria designates the brand product as preferred, (i.e. The following NCPDP fields below will be required on 340B transactions. 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. 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. The claim may be a multi-line compound claim. Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. For DEA Schedule 2 through 5 drugs, 85 percent of the days' supply of the last fill must lapse before a drug can be filled again. Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Required when Other Amount Claimed Submitted Qualifier (479-H8) is used. Required if utilization conflict is detected. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORMULARY SELECTION. All services to women in the maternity cycle. 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. 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. Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. DISPENSING FEE CONTRACTED/REIMBURSABLE AMOUNT. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT, Required for all COB claims with Other Coverage Code of 2 or 4. Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits, 3 = Other Coverage Billed Claim not Covered. 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. Provided for informational purposes only. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. Required when Approved Message Code (548-6F) is used. If a member calls the call center, the member will be directed to have the pharmacy call for the override. Required when there is payment from another source. Instructions on how to complete the PCF are available in this manual. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. It is used when a sender notifies the receiver of drug utilization, drug evaluations, or information on the appropriate selection to process the claim/encounter. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. Required when Patient Pay Amount (5o5-F5) includes co-pay as patient financial responsibility. 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. PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER, Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. *Note: Code 09 is a negative amount and is not a valid option for field 351-NP. %PDF-1.6 % Required when Basis of Cost Determination (432-DN) is submitted on billing. The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Required if the identification to be used in future transactions is different than what was submitted on the request. 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. Required if Other Amount Claimed Submitted (480-H9) is greater than zero (0). WebExamples of Reimbursable Basis in a sentence. 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. ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. Figure 4.1.3.a. 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. 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 additional text is needed for clarification or detail. Required when necessary for patient financial responsibility only billing. : 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.. 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. 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. Pharmacies may use the number 8 in Field # 420-DK instead of obtaining a PA for non-covered ingredients to allow the claim to pay for the ingredients that are considered a covered benefit. Providers must submit accurate information. Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Non-maintenance products submitted by a pharmacy for mail-order prescriptions will deny. No products in the category are Medical Assistance Program benefits. Required when there is payment from another source. 01 = Amount applied to periodic deductible (517-FH) 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. Required if needed by receiver to match the claim that is being reversed. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. ), SMAC, WAC, or AAC. The Field is mandatory for the Segment in the designated Transaction. Required if Previous Date of Fill (530-FU) is used. Required - Enter total ingredient costs even if claim is for a compound prescription. Required only for secondary, tertiary, etc., claims. Required when necessary for plan benefit administration. 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. 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. Required when needed to specify the reason that submission of the transaction has been delayed. "C" indicates the completion of a partial fill. 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. For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Required for this program when the Other Coverage Code (308-C8) of "3" is used. Required if this field is reporting a contractually agreed upon payment. Exceptions are granted only when the pharmacy is able to document that appropriate action was taken to meet filing requirements and that the pharmacy was prevented from filing as the result of extenuating unforeseen and uncontrollable circumstances. Appeals may be sent to: With few exceptions, providers are required to submit claims electronically. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website. 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. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). %PDF-1.5 % 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). It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. Required if necessary as component of Gross Amount Due. 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. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Only members have the right to appeal a PAR decision. Required if Other Payer Amount Paid (431-Dv) is used. 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. Imp Guide: Required, if known, when patient has Medicaid coverage. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Please refer to the specific rules and requirements regarding electronic and paper claims below. 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. 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. Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. 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. 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. Prior authorization requests for some products may be approved based on medical necessity. Required if needed to provide a support telephone number of the other payer to the receiver. 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 - If claim is for a compound prescription, enter "0. Required when Preferred Product ID (553-AR) is used. 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. Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). Appeals to the Office of Administrative Courts must be filed in writing within 60 days from the mailing date of the reconsideration denial. Copies of all forms necessary for submitting claims are also available on the Pharmacy Resources web page of the Department's website. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. 523-FN NCPDP Telecommunication Standard Version/Release #: Provider Relations Help Desk Information: NCPDP Telecommunication version 5.1 until TBD. Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required.". If there is a marketplace shortage for the generic version of the prescribed drug and only the brand-name product is available, claim will pay with DAW 8. Required when Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. 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 if this value is used to arrive at the final reimbursement. 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. hbbd```b``} DL`D^A$KT`H2nfA H/# -~$G@3@"@*Z? Timely filing for electronic and paper claim submission is 120 days from the date of service. Required when Basis of Cost Determination (432-DN) is submitted on billing. 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 original fills for these claims have no authorized refills a new RX number is required. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. Required when Basis of Cost Determination (432-DN) is submitted on billing. 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). 10 = Amount Attributed to Provider Network Selection (133-UJ) The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. For DAW 8-generic not available in marketplace or DAW 9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Patient Requested Product Dispensed. If the medication has been determined to be family planning or family planning- related, it should be documented in the prescription record. For non-mail order transactions, there is a maximum 20-day accumulation allowed every rolling 180 days. ADDITIONAL MESSAGE INFORMATION CONTINUITY. 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. 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. B. 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 These records must be maintained for at least seven (7) years. Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. 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. NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. 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. Providers should also consult the Code of Colorado Regulations (10 C.C.R. Required when other insurance information is available for coordination of benefits. Pharmacies must complete third-party information on the PCF and submit documentation from the third-party payer of payment or lack of payment. It is used for multi-ingredient prescriptions, when each ingredient is reported. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). WebExamples of Reimbursable Basis in a sentence. Date of service for the Associated Prescription/Service Reference Number (456-EN). WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). Figure 4.1.3.a. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. ), SMAC, WAC, or AAC. 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. The Helpdesk is available 24 hours a day, seven days a week. Required - If claim is for a compound prescription, list total # of units for claim. If the claim is denied, pharmacy benefit manager will send one or more denial reason(s) that identify the problem(s). Drugs administered in the hospital are part of the hospital fee. Required if Help Desk Phone Number (550-8F) is used. Required if any other payment fields sent by the sender.

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