The offer to counsel shall be face-to-face communication whenever practical or by telephone. Required for partial fills. Required when any other payment fields sent by the sender. Required if Help Desk Phone Number (550-8F) is used. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID. B. Required if Previous Date Of Fill (530-FU) is used. 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 WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. 1710 0 obj <> endobj Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. 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 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. If reversal is for multi-ingredient prescription, the value must be 00. If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. COVID-19 early refill overrides are not available for mail-order pharmacies. ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Required when this value is used to arrive at the final reimbursement. 1-5 = Refill number - Number of the replenishment, 8 = Substitution Allowed-Generic Drug Not Available in Marketplace, 1-99 = Authorized Refill number - with 99 being as needed, refills unlimited, 8 = Process Compound For Approved Ingredients. All electronic claims must be submitted through a pharmacy switch vendor. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. 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. Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. Durable Medical Equipment (DME), these must be billed as a medical benefit on a professional claim. Requests for Reconsideration must be filed in writing with the pharmacy benefit manager within 60 days of the most recent claim or prior reconsideration denial. The "***" indicates that the field is repeating. 340B Information Exchange Reference Guide - NCPDP Imp Guide: Required, if known, when patient has Medicaid coverage. 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. Express Scripts Required if needed to match the reversal to the original billing transaction. Substitution Allowed - Pharmacist Selected Product Dispensed, NCPDP 22-M/I DISPENSE AS WRITTEN CODE~50021~ERROR LIST M/I DISPENSE AS WRITTEN CODE and return the supplemental message Submitted DAW code not supported. IV equipment (for example, Venopaks dispensed without the IV solutions). RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). This letter identifies the member's appeal rights. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Incremental and subsequent fills may not be transferred from one pharmacy to another. 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 Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. Required if this field could result in contractually agreed upon payment. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Required when Compound Ingredient Modifier Code (363-2H) is sent. 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. AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. Required when Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used. Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. Download Standards Membership in NCPDP is required for access to standards. 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. We anticipate that our pricing file updates will be completed no later than February 1, 2021. Services cannot be withheld if the member is unable to pay the co-pay. 06 = Patient Pay Amount (505-F5) 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Medication Requiring PAR - Update to Over-the-counter products. BASIS A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. Required when a repeating field is in error, to identify repeating field occurrence. : 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.. Appeals to the Office of Administrative Courts must be filed in writing within 60 days from the mailing date of the reconsideration denial. Required when needed per trading partner agreement. Required if needed to provide a support telephone number to the receiver. Providers must submit accurate information. Access to Standards RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET Providers should also consult the Code of Colorado Regulations (10 C.C.R. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL Health First Colorado is the payer of last resort. Required when necessary for patient financial responsibility only billing. DISPENSING FEE CONTRACTED/REIMBURSABLE AMOUNT. CMS began releasing RVU information in December 2020. A generic drug is not therapeutically equivalent to the brand name drug. Required when needed to provide a support telephone number of the other payer to the receiver. Required when Reason For Service Code (439-E4) is used. 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. 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/%. Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. 81J _FLy4AyGP(O Required if Basis of Cost Determination (432-DN) is submitted on billing. Required for partial fills. Payer Specifications D.0 The standard drug ingredient reimbursement methodology applies to the quantity dispensed with each fill. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. 1727 0 obj <>/Encrypt 1711 0 R/Filter/FlateDecode/ID[]/Index[1710 41]/Info 1709 0 R/Length 94/Prev 551050/Root 1712 0 R/Size 1751/Type/XRef/W[1 3 1]>>stream Required if utilization conflict is detected. endstream endobj startxref All pharmacy PARs must be telephoned, faxed, or submitted via Real Time Prior Authorization via EHR, by the prescribing physician or physician's agent to the Pharmacy Benefit Manager Support Center. The following lists the segments and fields in a Claim Billing or Claim Re-bill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Drugs administered in clinics, these must be billed by the clinic on a professional claim. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). 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 WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Pharmacies must complete third-party information on the PCF and submit documentation from the third-party payer of payment or lack of payment. Required if other insurance information is available for coordination of benefits. Sent when Other Health Insurance (OHI) is encountered during claims processing. 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. This document contains the specifications of six templates: Payer: Please list each transaction supported with the segments, fields and pertinent information on each transaction. 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. %%EOF For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual. Companion Document To Supplement The NCPDP VERSION Values other than 0, 1, 08 and 09 will deny. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes.
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