basis of reimbursement determination codes

OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT. 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. Cheratussin AC, Virtussin AC). CMS began releasing RVU information in December 2020. 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. 07 = Amount of Co-insurance (572-4U) Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. 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. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional All services to women in the maternity cycle. Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim. Prescription cough and cold products for all ages will not require prior authorization for Health First Colorado members. 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 Required when other insurance information is available for coordination of benefits. ), SMAC, WAC, or AAC. If reversal is for multi-ingredient prescription, the value must be 00. Required if Approved Message Code (548-6F) is used. The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational In addition, some products are excluded from coverage and are listed in the Restricted Products section. This letter identifies the member's appeal rights. 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. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT. Required if utilization conflict is detected. CMS began releasing RVU information in December 2020. 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. AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. 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. The Department does not pay for early refills when needed for a vacation supply. 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). Download Standards Membership in NCPDP is required for access to standards. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). The Helpdesk is available 24 hours a day, seven days a week. Please contact the Pharmacy Support Center with questions. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. Required - If claim is for a compound prescription, enter "0. 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. For all other information as it relates to family planning benefits, please visit the Maternal, Child and Reproductive Health billing manual web page. Required when needed per trading partner agreement. Required to identify the actual group that was used when multiple group coverage exist. Required when necessary to identify the Plan's portion of the Sales Tax. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. Pharmacies that have an electronic tracking system shall review prescriptions in will-call status on a daily basis and enter a reversal of prescriptions not picked up within 10 days of billing. Required when additional text is needed for clarification or detail. In an emergency, when a PAR cannot be obtained in time to fill the prescription, pharmacies may dispense a 72-hour supply (3 days) of covered outpatient prescription drugs to an eligible member by calling the Pharmacy Support Center. A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). 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 use of inaccurate or false information can result in the reversal of claims. 1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads. Required for the partial fill or the completion fill of a prescription. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). WebExamples of Reimbursable Basis in a sentence. Mental illness as defined in C.R.S 10-16-104 (5.5). The following lists the segments and fields in a Claim Billing or Claim Rebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. The situations designated have qualifications for usage ("Required if x", "Not required if y"). 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. NCPDP Telecommunication Standard Version/Release #: Provider Relations Help Desk Information: NCPDP Telecommunication version 5.1 until TBD. Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. Parenteral Nutrition Products 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. Providers who consistently submit five or fewer claims per month, Claims that are more than 120 days from the date of service that require special attachments, and, 2 = Other coverage exists - payment collected, 3 = Other coverage exists - this claim not covered, 4 = Other coverage exists - payment not collected, Required when submitting a claim for member w/ other coverage, 1 = Substitution Not Allowed by Prescriber, 8 = Substitution Allowed - Generic Drug Not Available in Marketplace, 9 = Substitution Allowed by Prescriber but Plan Requests Brand. Required when Patient Pay Amount (505-F5) includes deductible. Sent when DUR intervention is encountered during claim 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. 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 transaction. 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 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.) Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. 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. Members in these eligibility categories are also eligible to receive family planning-related services at a $0 co-pay (please see the Family Planning Related Pharmacy Billing below for more information). AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORMULARY SELECTION. Required if Other Payer Reject Code (472-6E) is used. : 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.. Date of service for the Associated Prescription/Service Reference Number (456-EN). INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT. 677 0 obj <>stream Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. 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. Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. PARs are reviewed by the Department or the pharmacy benefit manager. Required if this field is reporting a contractually agreed upon payment. Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. Figure 4.1.3.a. Required when necessary to identify the Patient's portion of the Sales Tax. 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 Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required.". COMPOUND INGREDIENT BASIS OF COST DETERMINATION. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. If there is more than a single payer, a D.0 electronic transaction must be submitted. 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. Drug used for erectile or sexual dysfunction. endstream endobj startxref 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. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). 523-FN This requirement stems from the Social Security Act, 42 U.S.C. *Note: Code 09 is a negative amount and is not a valid option for field 351-NP. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. Required when this value is used to arrive at the final reimbursement. 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 The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication. 04 = Amount Exceeding Periodic Benefit Maximum (520-FK) 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. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. FDA as "investigational" or "experimental", Dietary needs or food supplements (see Appendix P for a list), Medicare Part D drugs for Part D eligible members, including compound claims that contain a drug not listed on the dual eligible drug list. Applicable co-pay is automatically deducted from the provider's payment during claims processing. Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. Required when there is payment from another source. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Brand Drug Dispensed as a Generic, Substitution Not Allowed - Brand Drug Mandated by Law, Substitution Allowed - Generic Drug Not Available in Marketplace. 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. COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT, 03 = Bank Information Number (BIN) Card Issuer ID. Members within this eligibility category will not be subject to utilization management policies as outlined in the Appendix P, Preferred Drug List (PDL) or Appendix Y. The following NCPDP fields below will be required on 340B transactions. Enter the ingredient drug cost for each product used in making the compound. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). Required when needed for receiver claim determination when multiple products are billed. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Only members have the right to appeal a PAR decision. Pharmacies can submit these claims electronically or by paper. 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. 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.