Pharmacy Billing Manual

• Pharmacy Requirements and Benefits
• 1990 OBRA Rebate Program
• Prior Authorization Request (PAR) Process
  • Medications Requiring a PAR
  • Primary Insurance and PAR Requirements
  • Guidelines Used by the Department for Determining PAR Criteria
  • Generic Mandate
• Dispensing Requirements
  • Refill Too Soon Policy
  • Tamper Resistant Prescription Pads
  • Compounded Prescriptions
  • Maximum Day Supply
  • Incremental Fills and/or Prescription Splitting
  • Emergency Three-Day Supply
  • Lost/Stolen/Damaged/Vacation Prescriptions
  • Counseling
  • Dispense As Written (DAW) Override Codes
    • Co-Pay
  • Reversals
  • Retention of Records
  • 340B Claims Processing
  • Mail Order
• Family Planning Pharmacy Billing for Special Populations
  • Emergency Medical Services (EMS)
  • Expanded Income Family Planning Limited (FAMPL)
    • Billing Requirements
• Restricted Products
• Exclusions
• Pharmacy Helpdesk
• Temporary COVID-19 Policy and Billing Changes
  • Zero Co-Pay
  • EUA COVID-19 Antivirals Claim Requirements
• Billing Information
  • Timely Filing Requirements
  • Rebilling Denied Claims
    • Ordering, Prescribing or Referring (OPR) Providers
    • Reuse of Rx Numbers
    • Delayed Processing by Third-Party Payers
    • Retroactive Member Eligibility
    • Delayed Notification to the Pharmacy of Eligibility
    • Extenuating Circumstances
  • Request for Reconsideration
    • Appealing Reconsideration Denials
• Paper Claim Submission Requirements
• Instructions for Completing the Pharmacy Claim Form
  • Electronic Claim Submission Requirements
• D.0 General Information
  • Transactions Supported
  • Field Legend for Columns
• Claim Billing/Claim Rebill Transaction
• Response Claim Billing/Claim Rebill Payer Sheet Template
  • Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response
  • General Information
  • 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
  • General Information
  • Claim Reversal Transaction
• Response Claim Reversal Payer Sheet Template
  • Claim Reversal Accepted/Approved Response
  • General Information
  • Claim Reversal Accepted/Approved Response
  • Claim Reversal Accepted/Rejected Response
  • Claim Reversal Rejected/Rejected Response
• Revision Log

Pharmacy Requirements and Benefits

This pharmacy billing manual explains many of the Colorado Department of Health Care Policy & Financing's (the Department) policies regarding billing, provider responsibilities, and program benefits. Providers should also consult the Code of Colorado Regulations (10 C.C.R. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements.

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1990 OBRA Rebate Program

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. 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. In addition, some products are excluded from coverage and are listed in the Restricted Products section. 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.

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Prior Authorization Request (PAR) Process

Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program.

The procedure to request a PAR and the medications that require a PAR are outlined in Appendix P - Pharmacy Benefit Prior Authorization Procedures and Criteria located on the Pharmacy Resources web page.

PARs are reviewed by the Department or the pharmacy benefit manager. 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. Notification of PAR approval or denial is sent to each of the following parties:

• Requesting physician
• Proposed rendering provider (if identified on the PAR)
• Member

In addition to stating whether the PAR has been approved or denied, a PAR denial notification letter is sent to members. This letter identifies the member's appeal rights. Only members have the right to appeal a PAR decision.

If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax.

Approval of a PAR does not guarantee payment. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. Some claim submission requirements include timely filing, eligibility requirements, pursuit of third-party resources, and required attachments included. A PAR approval does not override any of the claim submission requirements.

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Medications Requiring a PAR

• Certain restricted drugs
• 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
• 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

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Primary Insurance and PAR Requirements

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.

Note: This prior authorization override request with the Helpdesk only applies when claim records indicate that primary insurance was successfully billed first and if the medication is a covered pharmacy benefit. Refer to Appendix P and/or the Preferred Drug List (PDL) located on the Pharmacy Resources web page to find out if a medication is a covered pharmacy benefit.

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Guidelines Used by the Department for Determining PAR Criteria

In determining what drugs should be subject to prior authorization, the following criteria is used:

• 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

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Generic Mandate

Most brand-name drugs with a generic therapeutic equivalent are not covered by the Health First Colorado program.

Members can receive a brand name drug without a PAR if:

• Only a brand name drug is manufactured.
• A generic drug is not therapeutically equivalent to the brand name drug.
• The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication.
• The drug is for the treatment of:
  • Mental illness as defined in C.R.S 10-16-104 (5.5),
  • Treatment of cancer,
  • Treatment of epilepsy, or
  • Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS).

Members may receive a brand name drug with a PAR if:

• A member has tried the generic equivalent but is unable to continue treatment on the generic drug and criteria is met for medication.
• 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.

Refer to the Pharmacy Prior Authorization Form located on the Pharmacy Resources web page under the Pharmacy Prior Authorization Request section.

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Dispensing Requirements

Refill Too Soon Policy

For DEA Schedule 2 through 5 drugs, 85 percent of the days' supply of the last fill must lapse before a drug can be filled again. For non-scheduled drugs, 75 percent of the days' supply of the last fill must lapse before a drug can be filled again. A 7.5 percent tolerance is allowed between fills for Synagis. 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. For non-mail order transactions, there is a maximum 20-day accumulation allowed every rolling 180 days. 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. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center.

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Tamper Resistant Prescription Pads

All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. This requirement stems from the Social Security Act, 42 U.S.C. 1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. Visit the Pharmacy Resources web page for more information about Tamper-Resistant Prescription Pads/Paper requirements and features.

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Compounded Prescriptions

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. A PAR is only necessary if an ingredient in the compound is subject to prior authorization. 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. The Health First Colorado program does not pay a compounding fee.

SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2).

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Maximum Day Supply

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.

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Incremental Fills and/or Prescription Splitting

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.

Exception for DEA Schedule II medications: Initial Incremental fills are allowed for DEA Schedule II prescription drugs dispensed to ALL members. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements.

Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. Incremental and subsequent fills may not be transferred from one pharmacy to another. The standard drug ingredient reimbursement methodology applies to the quantity dispensed with each fill. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date.

All claims for incremental and subsequent fills require valid values in the following fields:

• 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)

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. Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim.

Refer to the payer sheet grid below for more detailed requirements regarding each field.

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Emergency Three-Day Supply

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 contacting the Pharmacy Support Center. An emergency is any condition that is life-threatening or requires immediate medical intervention.

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Lost/Stolen/Damaged/Vacation Prescriptions

The Department does not pay for early refills when needed for a vacation supply.

The Health First Colorado program will cover lost, stolen or damaged medications once per lifetime for each member. Pharmacies must contact the Pharmacy Support Center for overrides for lost, stolen, or damaged prescriptions. If a member calls the call center, the member will be directed to have the pharmacy call for the override. Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication.

Note: If the medication was lost or damaged as a result of a natural disaster, the replacement of the medication will not count toward the once-per-lifetime limit.

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Counseling

In addition to any other requirements at 3 CCR 719-1 Section 1.00.18, 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. The offer to counsel shall be face-to-face communication whenever practical or by telephone. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. These records must be maintained for at least seven (7) years.

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Dispense As Written (DAW) Override Codes

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Co-Pay

Effective July 1, 2023, Health First Colorado members do not have a pharmacy co-pay. 

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Reversals

If the member does not pick up the prescription from the pharmacy within 14 calendar days, the prescription must be reversed on the 15th calendar day. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. 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. In no case, shall prescriptions be kept in will-call status for more than 14 days.

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Retention of Records

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. 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.

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340B Claims Processing

The following NCPDP fields are required on 340B covered outpatient drug claims.

Refer to the 340B Policies and Procedures Manual for more information related to 340B billing.

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Mail Order

Enrolled Medicaid fee-for-service (FFS) members have the option to receive their outpatient medications through mail delivery.

Pharmacies enrolled as a mail order pharmacy specialty type 460 may only bill for outpatient maintenance medications for chronic conditions. Pharmacies enrolled specifically as Mail Order will receive denials for non-maintenance medications.

Local and out-of-state retail pharmacies other than mail order pharmacies may provide mail delivery 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.

Health First Colorado does not pay delivery fees.

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Family Planning Pharmacy Billing for Special Populations

Emergency Medical Services (EMS) 

The Emergency Medical Services (EMS) benefit plan covers both family planning and family planning-related medications for individuals who would otherwise be eligible for Health First Colorado coverage, but do not meet citizenship requirements. EMS is also referred to as “Emergency Medical and Reproductive Health Program.”

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Expanded Income Family Planning Limited (FAMPL) 

The Family Planning Limited (FAMPL) benefit plan covers family planning and family planning-related services for eligible individuals with an income above the Medicaid requirement.

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Billing Requirements

Refer to the Family Planning Benefit Expansion for Special Populations Billing Manual for more information on family planning benefits for special populations.

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Restricted Products

The Health First Colorado program restricts or excludes coverage for some drug categories. Refer to Appendix P located on the Billing Manuals web page for more information.

Restricted products by participating companies are covered as follows:

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Exclusions

The following are not benefits of the Health First Colorado program:

• DESI drugs and any drug if by its generic makeup and route of administration, it is identical, related, or similar to a less than effective drug identified by the FDA
• Drugs classified by the U.S.D.H.H.S. 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
• Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate Program.
• Fertility drugs
• IV equipment (for example, Venopaks dispensed without the IV solutions). Nursing facilities must furnish IV equipment for their patients.
• Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc.
• Spirituous liquors of any kind
• Drug used for erectile or sexual dysfunction

The following are not pharmacy benefits of the Health First Colorado program:

• Drugs administered in the physician's office must be billed by the physician as a medical benefit on a professional claim.
• Drugs administered in clinics must be billed by the clinic on a professional claim. Drugs administered in a dialysis unit are part of the dialysis fee or billed on a professional claim. Drugs administered in the hospital are part of the hospital fee.
• Durable Medical Equipment (DME) must be billed as a medical benefit on a professional claim.
• Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility.

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Pharmacy Helpdesk

The pharmacy benefit manager provides a Pharmacy Support Center to handle clinical, technical and member calls. The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. The Helpdesk is available 24 hours a day, seven (7) days a week.

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Temporary COVID-19 Policy and Billing Changes

Zero Co-Pay

Health First Colorado is waiving co-pay amounts for medications related to COVID-19 when ICD-10 diagnosis code U07.1, U09.9, Z20.822, Z86.16, J12.82, Z11.52, B99.9, J18.9, Z13.9, M35.81, M35.89, Z11.59, U07.1, B94.8, O98.5, Z20.818, Z20.828, R05, R06.02, or R50.9 is entered on the claim transmittal. Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription.

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. 

Contact the Pharmacy Support Center with questions.

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EUA COVID-19 Antivirals Claim Requirements

COVID-19 medications that were procured by the federal government are free of cost to pharmacy providers. 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: 

• Ingredient Cost = $0.01 per unit 
• Note: Colorado’s Pharmacy Benefit Manager, Magellan, will force a $0 cost in the end.
• 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.
• DUR (440-E5) = DD, ER, HD or PG
• Dispensing (Incentive) Fee = Standard dispense fee based on a pharmacy’s total annual prescription volume will still apply.

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Billing Information

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. 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). All electronic claims must be submitted through a pharmacy switch vendor. Claims that cannot be submitted through the vendor must be submitted on paper.

Refer to the specific rules and requirements regarding electronic and paper claims below.

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Timely Filing Requirements

Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. Timely filing for electronic and paper claim submission is 120 days from the date of service.

Pharmacies should retrieve their Remittance Advice (RA) or X12N 835 through the Provider Web Portal. Claims that do not result in the Health First Colorado program authorizing reimbursement for services rendered may be resubmitted. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. If the reconsideration is denied, the final option is to appeal the reconsideration.

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Rebilling Denied Claims

Pharmacies may electronically rebill denied claims when the claim submission is within 120 days of the date of service. Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. Pharmacies should continue to rebill until a final resolution has been reached. Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim.

Copies of all forms necessary for submitting claims are located on the Pharmacy Resources web page. Instructions on how to complete the PCF are available in this manual. All necessary forms should be submitted to Magellan Rx Management at:

Magellan Health Service
Attention Paper Claims Processing
P.O. Box 85042
Richmond, VA 23242

There are four exceptions to the 120-day rule:

• Delayed processing by third party payers
• Retroactive member eligibility
• Delayed notification to the pharmacy of eligibility
• Extenuating circumstances

Each of these exceptions is detailed below along with the specific instructions for submitting claims.

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Ordering, Prescribing or Referring (OPR) Providers

Pursuant to 42CFR 455.10(b) and 42CFR 455.440, Health First Colorado will not pay for prescriptions written by unenrolled prescribers. 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. Enrolling in Health First Colorado as an OPR provider:

• Does not obligate you to see Health First Colorado members,
• 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
• Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately.

If an OPR prescriber does not wish to enroll with Health First Colorado they must refer their patients to an enrolled prescriber, otherwise claims will deny. Refer to the OPR Provider Information section of the Provider Enrollment web page for more detailed information about enrollment and compliance with the Affordable Care Act.

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Reuse of Rx Numbers

The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. If the original fills for these claims have no authorized refills, a new Rx number is required.

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Delayed Processing by Third-Party Payers

Health First Colorado is the payer of last resort. 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. Pharmacies must complete third-party information on the PCF and submit documentation from the third-party payer of payment or lack of payment.

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Retroactive Member Eligibility

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.

Pharmacies can submit these claims electronically or by paper. Paper claims may be submitted using a pharmacy claim form.

Pharmacies may submit claims electronically by obtaining a PAR from the Pharmacy Support Center. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims.

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Delayed Notification to the Pharmacy of Eligibility

Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. 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.

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Extenuating Circumstances

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. Exceptions are granted only when the pharmacy is able to document that appropriate action was taken to meet filing requirements and that the pharmacy was prevented from filing as the result of extenuating unforeseen and uncontrollable circumstances. Pharmacy employee negligence, employer failure to provide sufficient, well-trained employees, or failure to properly monitor the activities of employees and agents (e.g., billing services) are not considered extenuating circumstances beyond the pharmacy provider's control. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below).

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Request for Reconsideration

When a pharmacy has exhausted all authorized rebilling procedures and has not been paid for a claim, the pharmacy may submit a Request for Reconsideration to the pharmacy benefit manager.

It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration.

Requests for Reconsideration must be filed in writing with the pharmacy benefit manager within 60 days of the most recent claim or prior reconsideration denial.

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. A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration.

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. The resubmitted request must be completed in the same manner as an original reconsideration request.

Refer to the Request for Reconsideration Form and instructions located under the Claim Forms and Attachments drop-down menu on the Provider Forms web page.

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Appealing Reconsideration Denials

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.

Representation by an attorney is usually required at administrative hearings. Appeals to the Office of Administrative Courts must be filed in writing within 60 days from the mailing date of the reconsideration denial. Appeals may be sent to:

Office of Administrative Courts
1525 Sherman Street - 4th Floor
Denver, CO 80203
Fax 303-866-5909

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Paper Claim Submission Requirements

With few exceptions, providers are required to submit claims electronically. Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required."

The following claims can be submitted on paper and processed for payment:

• 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
• Reconsideration claims.

Providers can submit only one claim per submission on the PCF, however, compound claims can be submitted. Providers must submit accurate information. The use of inaccurate or false information can result in the reversal of claims.

The PCF should be submitted to Magellan Rx Management agent at:

Magellan Health Service
Attention Paper Claims Processing
P.O. Box 85042
Richmond, VA 23242

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Instructions for Completing the Pharmacy Claim Form

Below are the completion instructions for the Colorado Pharmacy Claim Form (PCF-2) for Pharmacy Providers. The form is one-sided and requires an authorized signature. Providers must follow the instructions below and may only submit one (prescription) per claim. The claim may be a multi-line compound claim. If there is more than a single payer, a D.0 electronic transaction must be submitted.

Note: The format for entering a date is different than the date format in the POS system ***.

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Electronic Claim Submission Requirements

Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. The provider creates interactive claims one at a time and transmits them by toll-free telephone through a switch company to the pharmacy benefit manager. 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. If the claim is denied, pharmacy benefit manager will send one or more denial reason(s) that identify the problem(s).

Interactive claim submission must comply with Colorado D.0 Requirements. Providers must submit accurate information. The use of inaccurate or false information can result in the reversal of claims.

• An optional data element means that the user should be prompted for the field but does not have to enter a value.
• Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response.
• Electronic claim submissions must meet timely filing requirements.

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D.0 General Information

Effective February 25, 2017, pharmacies must code their systems using the D.0 Payer Sheets provided below when submitting pharmacy POS transactions to the Health First Colorado program for payment.

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Transactions Supported

Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

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Field Legend for Columns

Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e., not used) for this payer are excluded from the template.

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Claim Billing/Claim Rebill Transaction

The following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.

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Response Claim Billing/Claim Rebill Payer Sheet Template

Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response

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General Information

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Claim Billing/Claim Rebill PAID (or Duplicate of PAID) Response

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.

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Claim Billing/Claim Rebill Accepted/Rejected Response

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Claim Billing/Claim Rebill Rejected/Rejected Response

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NCPDP Version D.0 Claim Reversal Template

Request Claim Reversal Payer Sheet Template

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General Information

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Claim Reversal Transaction

The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.

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Response Claim Reversal Payer Sheet Template

Claim Reversal Accepted/Approved Response

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General Information

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Claim Reversal Accepted/Approved Response

The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.

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Claim Reversal Accepted/Rejected Response

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Claim Reversal Rejected/Rejected Response

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Revision Log