The following lists the segments and fields in a Claim Billing Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. 4 MeridianRx 2020 Payer Sheet v1 (Revised 9/1/2020) Version Information Version Date Page Field Notes 1.0 1/1/2017 Payer Sheet for 2017 2.0 1/1/2018 Payer Sheet for 2018 . M -Mandatory as defined by NCPDP R -Required as defined by the Processor RW -Situational as defined by Plan Transaction Header Segment: Mandatory Field # NCPDP Field Name Value Req Comment 11-A1 BIN Number 004336, 610591 012114, 013089 020396 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). Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. PCN List for BIN 610241 MeridianRx PCN Group ID Line of Business HPMMCD N/A Medicaid . Formore general information on Michigan Medicaid Health Plans, visitwww.michigan.gov/managedcare. 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. Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response. 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. Your pharmacy coverage is included in your medical coverage. Values other than 0, 1, 08 and 09 will deny. Cheratussin AC, Virtussin AC). PCN Phone Fax Email HPMMCD (Medicaid) 866-984-6462 877-355-8070 info@meridianrx.com . The MC plans will share with the Department the PAs that have been previously approved. Required on all COB claims with Other Coverage Code of 2. Hospital care and services. The CIN is located on all member cards including MMC plan cards. Use the following BIN/PCN when submitting claims to MORx: 004047/P021011511 Where should I send Medicare Part D excluded drug claims for participants? Non-maintenance products submitted by a pharmacy for mail-order prescriptions will deny. These medications (e.g., Paxlovid) still need to be billed to Colorado Medicaid, even though they are free of cost, and the claim requirements for billing free medications is outlined below: The Health First Colorado program uses the National Council on Prescription Drug Programs (NCPDP) electronic format and the Pharmacy Claim Form (PCF) to submit prescription drug claims. Information on the Safe Delivery Program, laws, and publications. Where should I send the Medicare Part D coordination of benefits (COB) claims? We are not compensated for Medicare plan enrollments. Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. Dispensing (Incentive) Fee = Standard dispense fee based on a pharmacys total annual prescription volume will still apply. P.O. Information on assistance with home repairs, heat and utility bills, relocation, home ownership, burials, home energy, and eligibility requirements. Information on adoption programs, adoption resources, locating birth parents and obtaining information from adoption records. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. Some claim submission requirements include timely filing, eligibility requirements, pursuit of third-party resources, and required attachments included. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan. Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. Any other pharmacy-related questions can be directed to the Medicaid Pharmacy Program at 1-800-437-9101. In addition, some products are excluded from coverage and are listed in the Restricted Products section. 01 = Amount applied to periodic deductible (517-FH) 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. . Interactive claim submission must comply with Colorado D.0 Requirements. Instructions for checking enrollment status, and enrollment tips can be found in this article. These items will remain the responsibility of the MC Plans. Required if Patient Pay Amount (505-F5) includes co-pay as patient financial responsibility. Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. correct diagnosis) are met, according to the member's managed care claims history. HFS > Medical Clients > Managed Care > MCO Subcontractor List. Required if Other Payer Amount Paid (431-Dv) is used. A PBM/processor/plan may choose to differentiate different plans/benefit packages with the use of unique PCNs. Completed PA forms should be sent to (800)2682990 . 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. 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. If the reconsideration is denied, the final option is to appeal the reconsideration. Instructions for checking enrollment status, and enrollment tips can be found in this article. 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. BIN: 610084 PCN: DRMTUA01 = Test (after 1/1/2012) Processor: Conduent Effective as of: June 1, 2017 NCPDP Telecommunication Standard Version/Release D. 0 NCPDP Data Dictionary Version Date: April 2017 NCPDP External Code List Version Date: April 2017 Updated: March 23, 2021 - - Provider Relations: (800) 365-4944 - - Product may require PAR based on brand-name coverage. Sent when DUR intervention is encountered during claim adjudication. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Resources and information to assist in assuring firearm safety for families in the state of Michigan. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Information on Adult Protective Services, Independent Living Services, Adult Community Placement Services, and HIV/AIDS Support Services. Prior authorization requirements may be added to additional drugs in the future. The North Carolina Medicaid Pharmacy Program offers a comprehensive prescription drug benefit, ensuring low-income North Carolinians have access to the medicine they need. Pediatric and Adult Edits Criteria are located at the bottom of the Prior Approval Drugs and Criteria page on NCTracks. not used) for this payer are excluded from the template. Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. 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. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements. ", 00 = If claim is a multi-ingredient compound transaction, Required - If claim is for a compound prescription, enter "00.". OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT, Required for all COB claims with Other Coverage Code of 2 or 4. 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. Medicare-Medicaid Coordination Private Insurance Innovation Center Regulations & Guidance Research, Statistics, Data & Systems Outreach & Education Back to HPMS Guidance History Clarification of Unique BIN (or BIN/PCN) Requirements as of January 1, 2012 Title Clarification of Unique BIN (or BIN/PCN) Requirements as of January 1, 2012 Date An optional data element means that the user should be prompted for the field but does not have to enter a value. Required if Other Amount Claimed Submitted (480-H9) is greater than zero (0). Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately. A. The Field is mandatory for the Segment in the designated Transaction. 07 = Amount of Co-insurance (572-4U) Newsletter . Federal regulation requires that drug manufacturers sign a national rebate agreement with the Centers for Medicare and Medicaid Services (CMS) to participate in the state Medical Assistance Program. Required if needed to identify the transaction. The above chart is the fourth page of the 2022 Medicare Part D pharmacy BIN and PCN list (H5337 - H7322). 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. The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. Although the services covered and the reimbursement rates of the two programs are very similar, the eligibility requirements and The Transaction Facilitator and CMS . We do not sell leads or share your personal information. These records must be maintained for at least seven (7) years. Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. State Government websites value user privacy. Resources & Links. If a pharmacy is made aware of eligibility after 120 days from the date of service, the pharmacy may submit the claims electronically by obtaining a PAR from the Pharmacy Support Center, or by paper using a pharmacy claim form. 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. Prescription cough and cold products may be approved with prior authorization for an acute condition for Dual Eligible (Medicare-Medicaid) members. The Processor Control Numbers (PCN) (Field 14A4) will change to: o "DRTXPROD" for Medicaid, CHIP, and CSHCN claims. PCN:ADV Group: RX8834 AmeriHealth Caritas General Provider Issues - Call PerformRx Provider Relations - 1-800-684-5502 Pharmacy Contracting Issues - Call PerformRx - 1-800-555-5690 AmeriHealth Caritas Member with Issues - Have the Member Call Perform Rx Member Services - 1-866-452-1040 Claims/Billing Issues - Call PerformRx - 1-800-684-5502 Unless otherwise communicated in the PDL or Appendix P, maintenance medications may be filled for up to a 100-day supply, and non-maintenance medications may be filled for up to a 30-day supply. 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) Benefits under STAR. The following MA Bulletins apply to 340B covered entities that bill the MA FFS program for 340B purchased drugs: MAB 99-17-09: Payment for Covered Outpatient Drugs MAB 24-18-21: Professional Dispensing Fee 2023 Pennsylvania Medical Assistance BIN/PCN/Group Numbers Last Updated December 22, 2022 Please contact the Pharmacy Support Center for a one-time PA deferment. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (402-D2) occur on the same day. Sent when DUR intervention is encountered during claim processing. No blanks allowed. The PDL was authorized by the NC General AssemblySession Law 2009-451, Sections 10.66(a)-(d). "P" indicates the quantity dispensed is a partial fill. Medicaid Publication Date June 1, 2021 BIN(s) 023880 PCN(s) KYPROD1 Processor MedImpact Healthcare Systems, Inc. Required if the identification to be used in future transactions is different than what was submitted on the request. 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. Future Medicaid Update articles will provide additional details and guidance. The Michigan Department of Health and Human Services (MDHHS) is soliciting comments from the public on the Michigan Medicaid Health Plan Common Formulary. Please Note: Physician administered (J-Code) drugs that are not listed on the Medicaid Pharmacy List of Reimbursable Drugs and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) as listed in sections 4.4, 4.5, 4.6, and 4.7 of the Durable Medical Equipment, Prosthetics and Supplies Manual are not subject to the carve-out. Reports True iff the second item (a number) is equal to the number of letters in the first item (a word). Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. Claims that do not result in the Health First Colorado program authorizing reimbursement for services rendered may be resubmitted. A PAR approval does not override any of the claim submission requirements. Appeals to the Office of Administrative Courts must be filed in writing within 60 days from the mailing date of the reconsideration denial. during the calendar year will owe a portion of the account deposit back to the plan. 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. 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. The offer to counsel shall be face-to-face communication whenever practical or by telephone. The Medicare Coverage Gap Discount Program (Discount Program) makes manufacturer discounts available to eligible Medicare beneficiaries receiving applicable, covered Part D drugs, while in the coverage gap. Please contact the plan for further details. It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. 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. Required if Basis of Cost Determination (432-DN) is submitted on billing. The Michigan Department of Health and Human Services' (MDHHS) Division of Environmental Health (DEH) uses the best available science to reduce, eliminate, or prevent harm from environmental, chemical, and physical hazards. Required - If claim is for a compound prescription, enter "0. Changes may be made to the Common Formulary based on comments received. Timely filing for electronic and paper claim submission is 120 days from the date of service. Appeals may be sent to: With few exceptions, providers are required to submit claims electronically. Pharmacies that are not enrolled in the FFS program as billing providers must enroll, in order to continue to serve Medicaid Managed Care members. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. Recursively sort the rest of the list, then insert the one left-over item where it belongs in the list, like adding a . Required if Other Payer patient Responsibility Amount (352-NQ) is submitted. On July 1, 2021, certain beneficiaries were enrolled in NC Medicaid Managed Care health plans, which will include the beneficiarys pharmacy benefits.

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