Request, Fine Print 1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads. A PAR is only necessary if an ingredient in the compound is subject to prior authorization. Your session is about to timeout due to inactivity. 01 = Amount Applied to Periodic Deductible (517-FH), 06 = Patient Pay Applied to Amount (only if Periodic Prior Payer was still Deductible in NCPDP version, MA = Medication Administration - use for vaccine. COVID-19 early refill overrides are not available for mail-order pharmacies. Required when there is payment from another source. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. Required - If claim is for a compound prescription, list total # of units for claim. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. Required if Previous Date of Fill (530-FU) is used. For all other information as it relates to family planning benefits, please visit the Maternal, Child and Reproductive Health billing manual web page. 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. The procedure to request a PAR and the medications that require a PAR are outlined in Appendix P - Pharmacy Benefit Prior Authorization Procedures and Criterialocated in the Pharmacy Prior Authorization Policies section of the Department's website. Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. Sent when DUR intervention is encountered during claim processing. Updated Lost/Stolen/Damaged/Vacation Prescriptions section - police report is no longer required for Stolen Medications, PAR Process: Updated notification letter section, Partial Fills and/or Prescription: Updated partial fill criteria, Updated contact information on page 15, to include Magellan's helpdesk info. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. Drug list criteria designates the brand product as preferred, (i.e. The offer to counsel shall be face-to-face communication whenever practical or by telephone. The Department does not pay for early refills when needed for a vacation supply. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. 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. 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, Family Planning and Family Planning-Related Services, 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. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. Pharmacy Billing Procedures and Forms section of the Department's website, NCPDP Uu~Daw 0 Cannot Be Submitted Ms Drug W/Avail Generics~50740~Error List Daw0 Cant Be Submit Ms Drug W/Avail Gen. Prescriber has indicated the brand name drug is medically necessary. Required if Other Payer patient Responsibility Amount (352-NQ) is submitted. 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. Required if Additional Message Information (526-FQ) is used. Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. This is the Magellan Mangers desk, Todd tried to assemble it himself and quickly decided that he needed a professional. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements. 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. Basis of Cost Determination = This is not a required field on the claim, but 05 (Acquisition) or 08 (340B/Disproportionate Share Pricing/Public Health Service) will be accepted if submitted on the claim. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Sent when claim adjudication outcome requires subsequent PA number for payment. Required if other payer has approved payment for some/all of the billing. An optional data element means that the user should be prompted for the field but does not have to enter a value. Nursing facilities must furnish IV equipment for their patients. Required if a repeating field is in error, to identify repeating field occurrence. Providers must follow the instructions below and may only submit one (prescription) per claim. Required - Enter total ingredient costs even if claim is for a compound prescription. Updates made throughout related to the POS implementation under Magellan Rx Management. Pharmacies can submit these claims electronically or by paper. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Drug used for erectile or sexual dysfunction. Metric decimal quantity of medication that would be dispensed for a full quantity. Appeals to the Office of Administrative Courts must be filed in writing within 60 days from the mailing date of the reconsideration denial. Prescription cough and cold products for all ages will not require prior authorization for Health First Colorado members. If a member calls the call center, the member will be directed to have the pharmacy call for the override. Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately. 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. Mental illness as defined in C.R.S 10-16-104 (5.5). Enrolled Medicaid fee-for-service (FFS) members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies. This requirement stems from the Social Security Act, 42 U.S.C. 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. Values other than 0, 1, 08 and 09 will deny. If a Medicaid member enters or leaves a nursing facility, the member may require a refill-too-soon override in order to receive his or her drugs. 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 additional text is needed for clarification or detail. If there is more than a single payer, a D.0 electronic transaction must be submitted. For more information related to physician administered drugs and billing for this population, please visit the Physician-Administered-Drug (PAD) Billing Manual. Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. If the original fills for these claims have no authorized refills a new RX number is required. Postpartum: Members who are eligible for all pregnancy related and postpartum services under Medicaid are eligible to receive services for the 365- day postpartum period at a $0 co-pay. JavaScript must be enabled in order for you to uses this site. 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. The claim may be a multi-line compound claim. 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. 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. Values other than 0, 1, 08 and 09 will deny. Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. 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. Required for 340B Claims. Sent when Other Health Insurance (OHI) is encountered during claim processing. Pharmacies that have an electronic tracking system shall review prescriptions in will-call status on a daily basis and enter a reversal of prescriptions not picked up within 10 days of billing. It was hard for him to admit that he couldnt do it but it was more important to him to have it done right. Providers must submit accurate information. Copies of all RAs, electronic claim rejections, and/or correspondence documenting compliance with timely filing and 60-day rule requirements must be submitted with the Request for Reconsideration. The resubmitted request must be completed in the same manner as an original reconsideration request. Required if needed to identify the transaction. The form is one-sided and requires an authorized signature. Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. These source documents, in addition to any work papers and records used to create electronic media claims, shall be retained by the provider for six 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 Other Payer ID (340-7C) is used. For non-scheduled drugs, 75 percent of the days' supply of the last fill must lapse before a drug can be filled again. Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). The Helpdesk is available 24 hours a day, seven days a week. Required if other insurance information is available for coordination of benefits. Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. 20 = 340B - Indicates that, prior to providing service, the pharmacy has determined the product being billed is purchased pursuant to rights available under Section 340B of the Public Health Act of 1992 including sub-ceiling purchases authorized by Section 340B (a) (10) and those made through the Prime Vendor Program (Section 340B(a)(8)). The maximum number of products that can be compared is 4. Does not obligate you to see Health First Colorado members. Member Contact Center1-800-221-3943/State Relay: 711. not used) for this payer are excluded from the template. 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. All services to women in the maternity cycle. 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.