Required if Patient Pay Amount (505-F5) includes deductible. hbbd```b``"`DrVH$0"":``9@n]bLlv #3~ ` +c 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. 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) Members in this eligibility category may receive up to a 12-month supply ofcontraceptiveswith a $0 co-pay. Paper claims may be submitted using a pharmacy claim form. Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. %%EOF The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. Prior authorization requests for some products may be approved based on medical necessity. Required if Quantity of Previous Fill (531-FV) is used. Required when necessary to identify the Patient's portion of the Sales Tax. 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 when the previous payer has financial amounts that apply to Medicare Part D beneficiary benefit stages. Required if other insurance information is available for coordination of benefits. Updates made throughout related to the POS implementation under Magellan Rx Management. Please see the payer sheet grid below for more detailed requirements regarding each field. 06 = Patient Pay Amount (505-F5) 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. NCPDP EC 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. 512-FC: ACCUMULATED DEDUCTIBLE AMOUNT RW: Provided for informational purposes only. Confirm and document in writing the disposition Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. Required if Basis of Cost Determination (432-DN) is submitted on billing. Required only when current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current. 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. Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. Please contact the Pharmacy Support Center for a one-time PA deferment. Required when Basis of Cost Determination (432-DN) is submitted on billing. Providers can collect co-pay from the member at the time of service or establish other payment methods. Pharmacies must call for overrides for lost, stolen, or damaged prescriptions. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND NON-PREFERRED FORMULARY SELECTION. Effective 10/22/2021, Updated policy for Quantity Limit overrides in COVID-19 section. 1 = Proof of eligibility unknown or unavailable. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. Drugs administered in clinics, these must be billed by the clinic on a professional claim. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. The PCF should be submitted to Magellan Rx Management agent at: Below are the completion instructions for the Colorado Pharmacy Claim Form (PCF-2) for Pharmacy Providers. 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. WebThese CPT codes are not used under Medicare Part B, but may be used by Medicaid, private health insurers, or Medicare Part D plan administrators in determining reimbursement for MTM services. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed. Required for partial fills. 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 The following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. : 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.. Required if needed to identify the transaction. 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. 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. Health First Colorado is the payer of last resort. 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 when text is needed for clarification or detail. Required when Approved Message Code (548-6F) is used. Copies of all forms necessary for submitting claims are also available on the Pharmacy Resources web page of the Department's website. All necessary forms should be submitted to Magellan Rx Management at: There are four exceptions to the 120-day rule: Each of these exceptions is detailed below along with the specific instructions for submitting claims. 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 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. 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 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. Enrolled Medicaid fee-for-service (FFS) members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies. Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. 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. 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. 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. Required when a repeating field is in error, to identify repeating field occurrence. ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Required if needed to supply additional information for the utilization conflict. 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. : 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.. Required if Previous Date of Fill (530-FU) is used. B. NOTE: This prior authorization override request with the Helpdesk only applies when claim records indicate that primary insurance was successfully billed first and if the medication is a covered pharmacy benefit. Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Flat Sales Tax Amount Paid (558-AW) is greater than zero (0). 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 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 Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. %%EOF Pharmacist may also use other HCPCS/CPT codes such as Evaluation and Management or immunization codes. The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. 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. Members of these eligibility categories will be subject to utilization management policies as outlined in the Appendix P, PDL or Appendix Y. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT, Required for all COB claims with Other Coverage Code of 2 or 4. Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). 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 This requirement stems from the Social Security Act, 42 U.S.C. 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. More information may be obtained in Appendix P in the Billing Manuals section of the Department's website. 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. Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. Required on all COB claims with Other Coverage Code of 3. Required when Benefit Stage Amount (394-MW) is used. 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 The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website. The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Required if Other Payer Amount Paid (431-Dv) is used. Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. ), SMAC, WAC, or AAC. Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax. WebExamples of Reimbursable Basis in a sentence. WebThese CPT codes are not used under Medicare Part B, but may be used by Medicaid, private health insurers, or Medicare Part D plan administrators in determining reimbursement for MTM services. %PDF-1.5 % Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Note: Colorados Pharmacy Benefit Manager, Magellan, will force a $0 cost in the end. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. Drugs administered in a dialysis unit are part of the dialysis fee or billed on a professional claim. A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. The claim may be a multi-line compound claim. An emergency is any condition that is life-threatening or requires immediate medical intervention. Required if Help Desk Phone Number (550-8F) is used. Figure 4.1.3.a. Required if this value is used to arrive at the final reimbursement. 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. 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.) Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)). Required for partial fills. COVID-19 early refill overrides are not available for mail-order pharmacies. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. The standard drug ingredient reimbursement methodology applies to the quantity dispensed with each fill. Required when needed to supply additional information for the utilization conflict. Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/NON-PREFERRED FORMULARY SELECTION. Services cannot be withheld if the member is unable to pay the co-pay. Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. If a pharmacy disagrees with the final decision of the pharmacy benefit manager, the pharmacy may file an appeal with the Office of Administrative Courts. 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 We anticipate that our pricing file updates will be completed no later than February 1, 2021. The use of inaccurate or false information can result in the reversal of claims. Required for partial fills. Representation by an attorney is usually required at administrative hearings. For all other information as it relates to family planning benefits, please visit the Maternal, Child and Reproductive Health billing manual web page. Source documents and source records used to create pharmacy claims shall be maintained in such a way that all electronic media claims can be readily associated and identified. Incremental and subsequent fills may not be transferred from one pharmacy to another. This letter identifies the member's appeal rights. Required if Reason for Service Code (439-E4) is used. 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. WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. BNR=Brand Name Required), claim will pay with DAW9. Pharmacies can submit these claims electronically or by paper. The total service area consists of all properties that are specifically and specially benefited. The value of '05' (Acquisition) or '08' (340B Disproportionate Share Pricing/Public Health Service) in the Basis of Cost Determination field (NCPDP Field # 423-DN). The "***" indicates that the field is repeating. In no case, shall prescriptions be kept in will-call status for more than 14 days. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT. 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 Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). 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. Interactive claim submission must comply with Colorado D.0 Requirements. A compounded prescription (a prescription where two or more ingredients are combined to achieve a desired therapeutic effect) must be submitted on the same claim. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required if the identification to be used in future transactions is different than what was submitted on the request. 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. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. Required when this value is used to arrive at the final reimbursement. 523-FN Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. 1710 0 obj <> endobj All services to women in the maternity cycle. Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. Please refer to the specific rules and requirements regarding electronic and paper claims below. Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. 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. 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. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Generic Drug Not in Stock, NCPDP EC 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. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required when a product preference exists that needs to be communicated to the receiver via an ID. Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Cheratussin AC, Virtussin AC). Required when needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required.". Local and out-of-state pharmacies may provide mail-order prescriptions for Medicaid members if they are enrolled with the Health First Colorado program and are registered and in good standing with the State Board of Pharmacy. Required when needed to provide a support telephone number. The table below A generic drug is not therapeutically equivalent to the brand name drug. Required when utilization conflict is detected. 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 for partial fills. Required when needed per trading partner agreement. 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. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required - If claim is for a compound prescription, enter "0. Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. Health First Colorado does not provide reimbursement for products by manufacturers that have not signed a rebate agreement unless the Department has made a determination that the availability of the drug is essential, such drug has been given 1-A rating by the Food and Drug Administration (FDA), and prior authorized. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a non-preferred formulary product. The situations designated have qualifications for usage ("Required if x", "Not required if y"). '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits, 3 = Other Coverage Billed Claim not Covered. The maternity cycle is the time period during the pregnancy and 365days' post-partum. 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 necessary for patient financial responsibility only billing. 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. Provided for informational purposes only. 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 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. AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Product may require PAR based on brand-name coverage. 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) 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 if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. Required if Other Payer ID (340-7C) is used. Required when the Other Payer Reject Code (472-6E) is used. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. EY Note: the pharmacy may call the Pharmacy Support Center to request a zero co-pay 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. A PAR approval does not override any of the claim submission requirements. The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Enter the ingredient drug cost for each product used in making the compound. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. If there is more than a single payer, a D.0 electronic transaction must be submitted. Required if Additional Message Information (526-FQ) is used. "Required When." Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional 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. Metric decimal quantity of medication that would be dispensed for a full quantity. 1750 0 obj <>stream Required when Previous Date Of Fill (530-FU) is used. 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 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.

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