Requests for timely filing waivers for extenuating circumstances must be made in writing and must contain a detailed description of the circumstance that was beyond the control of the pharmacy. 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. Drugs administered in clinics, these must be billed by the clinic on a professional claim. Required if Other Payer Amount Paid (431-Dv) is used. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Drugs administered in the hospital are part of the hospital fee. This requirement stems from the Social Security Act, 42 U.S.C. 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. It is used when a sender notifies the receiver of drug utilization, drug evaluations, or information on the appropriate selection to process the claim/encounter. JavaScript must be enabled in order for you to uses this site. If the original fills for these claims have no authorized refills a new RX number is required. These values are for covered outpatient drugs. 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. An optional data element means that the user should be prompted for the field but does not have to enter a value. not used) for this payer are excluded from the template. DESI drugs ** [applies to drugs with a Covered Outpatient Drug (COD) status equal to DESI - 5 (LTE/IRS drug for all indications or DESI 6 LTE/IRS drug withdrawn from market)]. Providers must submit accurate information. 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. The following NCPDP fields below will be required on 340B transactions. The claim may be a multi-line compound claim. 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. Providers must submit accurate information. Nursing facilities must furnish IV equipment for their patients. Applicable co-pay is automatically deducted from the provider's payment during claims processing. For all other information as it relates to family planning benefits, please visit the Maternal, Child and Reproductive Health billing manual web page. 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. Required if Patient Pay Amount (505-F5) includes co-pay as patient financial responsibility. Required if needed by receiver to match the claim that is being reversed. The following categories of members are exempt from co-pay: Effective July 1, 2022, the following changes will occur as it relates to family planning and family planning related pharmacy benefits. Required for partial fills. 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. Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. A PAR approval does not override any of the claim submission requirements. Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. ADDITIONAL MESSAGE INFORMATION CONTINUITY. Quantity Prescribed (Field # 460-ET) for ALL DEA Schedule II prescription drugs, regardless of incremental or full-quantity fills, Quantity Intended To Be Dispensed (Field # 344-HF), Days Supply Intended To Be Dispensed (Field # 345-HG). 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. If PAR is authorized, claim will pay with DAW1. 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. 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. This will allow the pharmacist to determine if the medication was prescribed in relation to a family planning visit (e.g., tobacco cessation and STI/STD medications). Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. Required if any other payment fields sent by the sender. NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. Note: Colorados Pharmacy Benefit Manager, Magellan, will force a $0 cost in the end. Required for partial fills. Drugs produced by companies that have signed a rebate agreement (participating companies) are generally a Health First Colorado program benefit but may be subject to restrictions. Pharmacies should continue to rebill until a final resolution has been reached. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). *FREE, next-day delivery on most orders to most areas. 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. The pharmacy benefit manager reviews the claim and immediately returns a status of paid or denied for each transaction to the provider's personal computer. No blanks allowed. 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. All claims for incremental and subsequent fills require valid values in the following fields: Please note: if a pharmacy submits a claim for a non-Schedule II medication and includes a value for quantity prescribed, it must be a valid value. No products in the category are Medical Assistance Program benefits. Member Contact Center1-800-221-3943/State Relay: 711. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. All Rights Reserved. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. 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 resubmitted request must be completed in the same manner as an original reconsideration request. The Health First Colorado program does not pay a compounding fee. Please refine your selection. A pharmacist or pharmacist designee shall offer counseling regarding the drug therapy to each Health First Colorado member with a new or refill prescription if the pharmacist or pharmacist designee believes that it is in the best interest of the member. Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately. 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. Pursuant to 42CFR 455.10(b) and 42CFR 455.440, Health First Colorado will not pay for prescriptions written by unenrolled prescribers. Required if needed to match the reversal to the original billing transaction. Required to identify the actual group that was used when multiple group coverage exist. Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Realspace Hs-Mg-2072 Espresso Magellan Manager Desk, 58-3/4 x 23-1/4 x 30". If the timely filing period expires due to a delayed or back-dated member eligibility determination, the claim is considered timely if received within 120 days from the date the member was granted backdated eligibility. A member has tried the generic equivalent but is unable to continue treatment on the generic drug and criteria is met for medication. The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication. Required if Other Payer patient Responsibility Amount (352-NQ) is submitted. Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (402-D2) occur on the same day. Request, Fine Print Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed. Pharmacies can submit these claims electronically or by paper. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. Product may require PAR based on brand-name coverage. The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. Provided for informational purposes only. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual. 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. All products in this category are regular Medical Assistance Program benefits. Effective 10/22/2021, Corrected formatting error; replaced "" with numeric "0", 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. The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication.
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