basis of reimbursement determination codes
Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program. 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 Download Standards Membership in NCPDP is required for access to standards. One of the other designators, "M", "R" or "RW" will precede it. Required - If claim is for a compound prescription, enter "0. Required when necessary to identify the Plan's portion of the Sales Tax. Required when Compound Ingredient Modifier Code (363-2H) is sent. Durable Medical Equipment (DME), these must be billed as a medical benefit on a professional claim. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. 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 Payer Specifications D.0 The pharmacy benefit manager processes both electronic and paper claims and provides claim, provider, eligibility, and PAR interfaces with the Medicaid Management Information System (MMIS). Pharmacies are expected to keep records indicating when member counseling was not or could not be provided. 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. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Only members have the right to appeal a PAR decision. RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET Required when Previous Date Of Fill (530-FU) is used. If the claim is denied, pharmacy benefit manager will send one or more denial reason(s) that identify the problem(s). Required if needed to supply additional information for the utilization conflict. Required for partial fills. 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 Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). WebExamples of Reimbursable Basis in a sentence. The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. For Transaction Code of "B2", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). The table below Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. If there is more than a single payer, a D.0 electronic transaction must be submitted. Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate 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 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. The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication. 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. Approval of a PAR does not guarantee payment. Parenteral Nutrition Products 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. 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. Maternal, Child and Reproductive Health billing manual web page. 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. Other Payer Bank Information Number (BIN). All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. Pharmacies should retrieve their Remittance Advice (RA) or X12N 835 through the Provider Web Portal. A generic drug is not therapeutically equivalent to the brand name drug. If reversal is for multi-ingredient prescription, the value must be 00. The Department does not pay for early refills when needed for a vacation supply. Required when other coverage is known, which is after the Date of Service submitted. Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. PRESCRIPTION/ SERVICE REFERNCE NUMBER QUALIFIER, Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). The table below Express Scripts 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 when Other Amount Paid (565-J4) is used. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. '2 = Other Override' required to override select Plan Limitations Exceeded for Maximum edits, 3 = Other Coverage Billed Claim not Covered. AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG. 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. Required when there is payment from another source. Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required.". More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. The total service area consists of all properties that are specifically and specially benefited. Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. These records must be maintained for at least seven (7) years. : 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.. The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication. 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. 0 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.