These source documents, in addition to any work papers and records used to create electronic media claims, shall be retained by the provider for seven years and shall be made readily available and produced upon request of the Secretary of the Department of Health and Human Services, the Department, and the Medicaid Fraud Control Unit and their authorized agents. Required if a repeating field is in error, to identify repeating field occurrence. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. Required if Previous Date of Fill (530-FU) is used. 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. 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. More information may be obtained in Appendix P in the Billing Manuals section of the Department's website. For all other information as it relates to family planning benefits, please visit the Maternal, Child and Reproductive Health billing manual web page. 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). Does not mean you will be listed as a Health First Colorado provider for patient assignment or referral, Allows you to continue to see Health First Colorado members without billing Health First Colorado, and. 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.) * Cough and cold products: Cough and cold products include combinations of narcotic and nonnarcotic cough suppressants, expectorants, and/or decongestants. 12 = Amount Attributed to Coverage Gap (137-UP) enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). Cost-sharing for members must not exceed 5% of their monthly household income. The Field is mandatory for the Segment in the designated Transaction. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. These records must be maintained for at least seven (7) years. Providers can collect co-pay from the member at the time of service or establish other payment methods. Required if Help Desk Phone Number (550-8F) is used. 07 = Amount of Co-insurance (572-4U) %PDF-1.6 % Required when Other Amount Claimed Submitted (480-H9) is used. Required when needed to communicate DUR information. Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. 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. The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER, Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). This dollar amount will be provided, if known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount. Indicates that the drug was purchased through the 340B Drug Pricing Program. 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 Required if Other Payer Amount Paid (431-Dv) is used. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. Provided for informational purposes only. Required when there is a known incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). Confirm and document in writing the disposition Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. Required if Quantity of Previous Fill (531-FV) is used. Required if necessary as component of Gross Amount Due. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. 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 for this program when the Other Coverage Code (308-C8) of "3" is used. INGREDIENT COST CONTRACTED/REIMBURSABLE AMOUNT. Required when Additional Message Information (526-FQ) is used. Required if Approved Message Code (548-6F) is used. Required when Basis of Cost Determination (432-DN) is submitted on billing. 06 = Patient Pay Amount (505-F5) Parenteral Nutrition Products The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. 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. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. 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. If PAR is authorized, claim will pay with DAW1. The form is one-sided and requires an authorized signature. Required when necessary to identify the Patient's portion of the Sales Tax. 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 if needed to identify the transaction. Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. 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. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. The use of inaccurate or false information can result in the reversal of claims. Effective 10/22/2021, Corrected formatting error; replaced "" with numeric "0", Added Real Time Prior Authorization via EHR to PAR Process, Updated to reflect billing changes to family planning and family planning-related services, Updated family planning-related section for clarity, Added primary insurance clarification to PAR Process and max day supply clarification to Dispensing Requirements, Added record maintenance requirements under Counseling, Retention of Records, and Signature Requirements, Removed requirement for providers to obtain a new override each fill for TPL/COB prior authorizations, Updated qualifier codes accepted in COB/ Other Payments under Claim Billing, Proposed rendering provider (if identified on the PAR), Non-preferred agents subject to the Preferred Drug List (PDL), Preferred agents with clinical criteria attached to the medication and all non-preferred agents subject to the Preferred Drug List (PDL) Over-the-counter (OTC) drugs that are not a regular Health First Colorado program benefit, Intravenous (IV) solutions with clinical criteria attached to the medication, Total Parenteral Nutrition (TPN) therapy and drugs, Significance of impact on the health of the Health First Colorado program population, Required monitoring of prescribing protocols to protect both the long-term efficacy of the drug and the public health, Potential for, or a history of, drug diversion and other illegal utilization, Appearance of the Health First Colorado program usage in amounts inconsistent with non- medical assistance program usage patterns, after adjusting for population characteristics, Clinical safety and efficacy compared to other drugs in that class of medications, Availability of more cost-effective comparable alternatives, Procedures where inappropriate utilization has been reported in medical literature, Performing auditing services with constant review on drug utilization. 01 = Amount Applied to Periodic Deductible (517-FH), 02 = Amount Attributed to ProductSelection/Brand Drug (134-UK), 03 = Amount Attributed to Sales Tax(523-FN), 04 = Amount Exceeding Periodic Benefit Maximum (520-FK), 06 = Patient Pay Amount (Deductible) (505-F5), 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection(135-UM), 10 = Amount Attributed to Provider Network Selection (133-UJ), 11 = Amount Attributed to Product Selection/Brand Non-Preferred FormularySelection(136-UN), 12 = Amount Attributed to Coverage Gap (137-UP), 13 = Amount Attributed to Processor Fee (571-NZ), MA = Medication Administration - use for vaccine. 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. Updated Partial Fill Section to read Incremental Fills and/or Prescription Splitting, Updated Quantity Prescribed valid value policy, Updated the diagnosis codes in COVID-19 zero copay section. 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. This value is the prescription number from the first partial fill. Required when Basis of Cost Determination (432-DN) is submitted on billing. 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. Note: The format for entering a date is different than the date format in the POS system ***. Required when Patient Pay Amount (505-F5) includes deductible. B. 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. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Sent if reversal results in generation of pricing detail. It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. Required if this field is reporting a contractually agreed upon payment. Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc. Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. 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. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. Required if other insurance information is available for coordination of benefits. Required if Basis of Cost Determination (432-DN) is submitted on billing. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. Colorado Pharmacy supports up to 25 ingredients. B. 523-FN 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. Required when this value is used to arrive at the final reimbursement. The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. Required when Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. 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. This document contains the specifications of six templates: Payer: Please list each transaction supported with the segments, fields and pertinent information on each transaction. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. The resubmitted request must be completed in the same manner as an original reconsideration request. 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. %PDF-1.5 % 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 Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Required when Previous Date Of Fill (530-FU) is used. Required when Patient Pay Amount (505-F5) includes an amount that is attributable to a patient's selection of a brand drug. hbbd```b``} DL`D^A$KT`H2nfA H/# -~$G@3@"@*Z? Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. The use of inaccurate or false information can result in the reversal of claims. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Required when Patient Pay Amount (505-F5) includes sales tax that is the financial responsibility of the member but is not also included in any of the other fields that add up to Patient Pay Amount. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Members who were formerly in foster care are co-pay exempt until their 26th birthday, Services provided by Community Mental Health Services, Members receiving a prescription for Tobacco Cessation Product. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. 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. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. Pharmacies must complete third-party information on the PCF and submit documentation from the third-party payer of payment or lack of payment. WebNCPDP standards have transformed the pharmacy industry, saving billions of dollars in health system costs while increasing patient safety and quality of care. 523-FN The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. 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. Providers should also consult the Code of Colorado Regulations (10 C.C.R. Values other than 0, 1, 08 and 09 will deny. Please see the payer sheet grid below for more detailed requirements regarding each field. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. Appeals may be sent to: With few exceptions, providers are required to submit claims electronically. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Please contact the Pharmacy Support Center for a one-time PA deferment. Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed. Cheratussin AC, Virtussin AC). 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. 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. "P" indicates the quantity dispensed is a partial fill. Required if Reason for Service Code (439-E4) is used. COVID-19 early refill overrides are not available for mail-order pharmacies. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override.

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