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 History

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 in the Pharmacy Prior Authorization Policies section of the Department's website.

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. To find out if a medication is a covered pharmacy benefit, refer to the Appendix P and/or the Preferred Drug List (PDL) located on the Pharmacy Resources web page.

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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.

The pharmacy Prior Authorization Form is available on the Pharmacy Resources web page of the Department's website.

 

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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. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website.

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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)

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

Please see 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 calling 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 call 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

DAW Code	DAW Description	Action	Description
DAW 0	No Product Selection Indicated	Allow	NCPDP Uu~Daw 0 Cannot Be Submitted Ms Drug W/Avail Generics~50740~Error List Daw0 Cant Be Submit Ms Drug W/Avail Gen
DAW 1	Substitution Not Allowed by Prescriber	Allow	Prescriber has indicated the brand name drug is medically necessary. Product may require PAR based on brand-name coverage. If PAR is authorized, claim will pay with DAW1.
		Not Supported	Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. For DAW 8-generic not available in marketplace or DAW 9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual
DAW 2	Substitution Allowed - Patient Requested Product Dispensed	Not Supported	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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual.
DAW 3	Substitution Allowed - Pharmacist Selected Product Dispensed	Not Supported	NCPDP 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual
DAW 4	Substitution Allowed - Generic Drug Not in Stock	Not Supported	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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual
DAW 5	Substitution Allowed - Brand Drug Dispensed as a Generic	Not Supported	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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual
DAW 6	Override	Not Supported	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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual
DAW 7	Substitution Not Allowed - Brand Drug Mandated by Law	Not Supported	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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual
DAW 8	Substitution Allowed - Generic Drug Not Available in Marketplace	Allow Billing ID = DAW8	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. The drug list will update as often as necessary to accommodate for drug shortages. If drug is on list, claim will pay.
		Not Supported All Non Billing ID = DAW8	NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. For DAW 8-generic not available in marketplace or DAW 9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual" If the drug is not on the list and the generic version is unavailable, contact the MRx contact center at 1-800-424-5275 for further assistance.
DAW 9	Allowed by Prescriber but Plan Requests Brand	Allow Formulary Ind = BNR	Drug list criteria designates the brand product as preferred, (i.e. BNR=Brand Name Required), claim will pay with DAW9.
		Allow Formulary Ind = NPP	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.
		Not Supported	NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. For DAW 8-generic not available in marketplace or DAW 9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual"

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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.

NCPDP Field Name & Number	Value	Description
Submission Clarification Code (420-DK)	20 = 340B Claim	Required for 340B Claims. The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. Indicates that the drug was purchased through the 340B Drug Pricing Program.
Basis of Cost Determination (423-DN)	05 = Acquisition Cost or 08 = Disproportionate Share Pricing	Required for 340B Claims. The value of '05' (Acquisition) or '08' (340B Disproportionate Share Pricing/Public Health Service) in the Basis of Cost Determination field (NCPDP Field # 423-DN).

For more information related to 340B billing, please visit the 340B Policies and Procedures Manual.

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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.”

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.

Billing Requirements

	Family Planning Services (FP)	Family Planning Related Services (FP-R)
Covered Services	Pharmacy FP services include contraceptive drugs, devices or products approved by the Federal Food and Drug Administration.	Pharmacy FP-R services include tobacco cessation products and drugs which treat sexually transmitted infections, lower genital tract and genital skin infections and urinary tract infections.
Claim Requirements	Not Applicable	“6-Family Plan” on field 461-EU
Billing Information	Contraceptives for members within the EMS eligibility category will not be subject to utilization management policies as outlined in the Appendix P, PDL or Appendix Y. Note: A provider may need to validate place of service to ensure accurate billing to the proper benefit. Contraceptives for members within the FAMPL eligibility category will be subject to utilization management policies as outlined in the Appendix P, PDL, or Appendix Y (as applicable).	If a FP-R drug is not on the Department created FP-R drug list, then the prescriber will need to complete a prior authorization request to confirm that the drug was prescribed in relation to a family planning visit.  Note: FP-R drugs are still subject to existing utilization management policies as outlined in the Appendix P, PDL or Appendix Y.   If the medication has been determined to be FP or FP-R, it should be documented in the prescription record.

For more information regarding family planning benefits for special populations, please visit the Family Planning Benefit Expansion for Special Populations Billing Manual. 

Restricted Products

The Health First Colorado program restricts or excludes coverage for some drug categories. More information may be obtained in Appendix P in the Billing Manuals section of the Department's website.

Restricted products by participating companies are covered as follows:

None	No products in the category are Medical Assistance Program benefits.
Limited	Prior authorization requests for some products may be approved based on medical necessity.
All	All products in this category are regular Medical Assistance Program benefits.

Category	Benefits
Anorexia (weight loss)	None
Weight gain	Limited
Cosmetic purposes or hair growth	None
Cough and cold *	Limited
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)]	None
Non-rebatable products	None
Fertility	None
Non-prescription drugs	Aspirin, Insulin, others Limited
Prenatal vitamins	All for females. None for males.
Other vitamins	Limited
Barbiturates	Limited
* Cough and cold products: Cough and cold products include combinations of narcotic and nonnarcotic cough suppressants, expectorants, and/or decongestants. Single agent antihistamines and their combination products with a decongestant are not considered to be cough and cold products and are regular Medical Assistance Program benefits. ** DESI drugs: DESI drugs are products that are declared "less than effective" by the FDA and are not a benefit of the Medical Assistance program.

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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, these must be billed by the physician as a medical benefit on a professional claim.
• Drugs administered in clinics, these 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), these 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 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. Please 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. Please 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 also available on the Pharmacy Resources web page of the Department's website. 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. Please visit the OPR section of the Department's website 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.

The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website.

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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 ***.

Field	Value	Comment
I. Member Information
Member's Medicaid ID #	Member's 7-character Medical Assistance Program ID	Required
Group ID	COMEDICAID	Default value on claim form
Relationship Code	1 = Cardholder	Default value on claim form
Member's Name	Last, First, MI	Required
Other Coverage Code	0 = Not specified 1 = No other coverage exists 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
Member's DOB	MM/DD/YYYY	Required
II. Pharmacy Information
Service Provider ID	NPI = National Provider Identifier	Required
Service Provider ID Qualifier	01 = NPI-National Provider Identifier	Required
III. Prescriber Information
Prescriber's Last Name	Last Name of Prescriber	Required
Prescriber's Phone #	Prescriber's Phone #	Required
Prescriber's ID	Prescriber's NPI, CO State License or DEA	Required Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017.
Prescriber's ID Qualifier	01 = NPI 08 = State License # 12 = DEA Number	Required
IV. Claim Information (Claim must be for same member as listed above)
Prescription #	Prescription # Assigned by Pharmacy	Required
Date Written	MM/DD/YYYY	Required
Date Filled	MM/DD/YYYY	Required
Fill #	00 = Original 01-99 = # of Refills Fill	Required
Prescription # Qualifier	0 = Blank 1 = Rx Billing	Required
Prescription Origin Code	1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile 5 = Pharmacy	Required
Days Supply	# of Days Prescription is Prescribed	Required
DAW Codes	0 = No Generic 1 = Substitution Not Allowed by Prescriber 8 = Substitution Allowed - Generic Drug Not Available in Marketplace 9 = Substitution Allowed by Prescriber but Plan Requests Brand	Values other than 0, 1, 08 and 09 will deny. The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code.
PA Type Code	0 = Not Specified
Quantity Prescribed	Metric Decimal Quantity	Required - If claim is for a compound prescription, list total # of units for claim.
Quantity Dispensed	Metric Decimal Quantity	Required - If claim is for a compound prescription, list total # of units for claim.
Product ID	NDC #	Required - If claim is for a compound prescription, enter "0."
Product ID Qualifier	00 = If claim is a multi-ingredient compound transaction 03 = National Drug Code (NDC)	Required - If claim is for a compound prescription, enter "00."
Submitted Ingredient Cost		Required - Enter total ingredient costs even if claim is for a compound prescription.
Total Charge		Required - Pharmacy's Usual and Customary Charge
Gross Amount Due		Required
Unit of Measure		Required
V. Other Payer Information
Other Payer Cov Type	01 = Primary	Required if Other Cov Code equals 2, 3, or 4
Other Payer Date	MM/DD/YYYY	Required if Other Cov Code equals 2, 3, or 4
Other Payer $ Paid		Required if Other Cov Code equals 2, 3, or 4
Other Payer $ Paid Qualifier	02 = Shipping 03 = Postage Service 04 = Administrative 05 = Incentive 06 = Cognitive 07 = Drug Benefit 09 = Compound Preparation Cost 10 = Sales Tax	Required if Other Cov Code equals 2, 3, or 4
Other Payer Reject Code	Value from Prior Payer	Required if Other Cov Code equals 3
Other Payer Patient Responsibility $	Value from Prior Payer	Required if Other Cov Code equals 4
Other Payer Patient Responsibility $ Qualifier	01 = Amount applied to periodic deductible (517-FH)  02 = Amount Attributed to Product Selection/Brand Drug (134-UK)  03 =Amount Attributed to Sales Tax (523-FN)  04 = Amount Exceeding Periodic Benefit Maximum (520-FK) 05 = Amount of Co-pay (518-FI) 06 = Patient Pay Amount (505-F5) 07 = Amount of Co-insurance (572-4U) 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 Formulary Selection (136-UN) 12 = Amount Attributed to Coverage Gap (137-UP) 13 = Amount Attributed to Processor Fee (571-NZ) *Note: Code 09 is a negative amount and is not a valid option for field 351-NP.	Required if Other Cov Code equals 4
Compound Claim	Blank 0 = Not a Claim Specified 1 = Not a Compound 2 = Claim is a Compound Claim	Required when claim is for a compound prescription
Diagnosis Code Qualifier	02 = ICD10 Code
Diagnosis Code	ICD10
RX Override	8 = Process Compound Claim for Approved Ingredients * In the future, Colorado plans to utilize other Rx Override fields.	Conditional - Needed to process claim for approved ingredients when claim is for a compound prescription
If the claim is a compound claim, complete the bottom section of the claim form to indicate each ingredient name, NDC quantity, and cost. Remember that there is a limit of one prescription per claim form.
Ingredient Name	Ingredient Name	Required when the claim is for a compound prescription
NDC	NDC Number of the Ingredient	Required when the claim is for a compound prescription
Quantity	Metric Decimal Quantity Dispensed	Required when the claim is for a compound prescription
Ingredient Cost Submitted		Required when the claim is for a compound prescription

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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.

Transaction Code	Transaction Name
B1	Billing
B3	Rebill
B2	Reversal

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Field Legend for Columns

Payer Usage Column	Value	Explanation	Payer Situation column
MANDATORY	M	The Field is mandatory for the Segment in the designated Transaction.	No
REQUIRED	R	The Field has been designated with the situation of "Required" for the Segment in the designated Transaction.	No
QUALIFIED REQUIREMENT	RW	"Required when." The situations designated have qualifications for usage ("Required if x", "Not required if y").	Yes

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.

 

Transaction Header Segment Questions	Check	Claim Billing/Claim Rebill If Situational, Payer Situation
This segment is always sent	X
Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Payer Issued	X

 

Transaction Header Segment		Claim Billing/Claim Rebill
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
101-A1	BIN Number	018902	M
101-A2	VERSION/RELEASE NUMBER	D0	M
103-A3	TRANSACTION CODE		M
104-A4	PROCESSOR CONTROL NUMBER	P303018902	M
109-A9	TRANSACTION COUNT		M	One transaction for B2 or compound claim, Four allowed for B1 or B3
202-B2	SERVICE PROVIDER ID QUALIFIER		M	Code qualifying the 'Service Provider ID' (Field # 201-B1) 01 - National Provider Identifier (NPI)
201-B1	SERVICE PROVIDER ID		M
401-D1	DATE OF SERVICE		M
110-AK	SOFTWARE VENDOR/CERTIFICATION ID	This will be provided by the provider's software vendor	M	Assigned when vendor is certified with Magellan Rx Management - If not number is supplied, populate with zeros

 

 

Insurance Segment Questions	Check	Claim Billing/Claim Rebill If Situational, Payer Situation
This segment is always sent	X

 

 

Insurance Segment Segment Identification (111 AM) = "04"		Claim Billing/Claim Rebill
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
302-C2	CARDHOLDER ID	12-Byte alpha/numeric ID	M	CO Medicaid identification number
312-CC	CARDHOLDER FIRST NAME		RW
313-CD	CARDHOLDER LAST NAME		RW
360-2B	MEDICAID INDICATOR	UNITED STATES AND CANADIAN PROVINCE POSTAL SERVICE	RW	Imp Guide: Required, if known, when patient has Medicaid coverage. Payer Requirement: Required in special situations when State issues instructions.
301-C1	GROUP ID	COMEDICAID	R
306-C6	PATIENT RELATIONSHIP CODE	1 = Subscriber	R

 

 

Patient Segment Questions	Check	Claim Billing/Claim Rebill If Situational, Payer Situation
This segment is always sent
This segment is situational	X

 

 

Patient Segment Segment Identification (111 AM) = "01"		Claim Billing/Claim Rebill
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
304-C4	DATE OF BIRTH	Format = CCYYMMDD	R
305-C5	PATIENT GENDER CODE		R
310-CA	PATIENT FIRST NAME		R
311-CB	PATIENT LAST NAME		R
335-2C	PREGNANCY INDICATOR		RW	Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility.
384-4X	PATIENT RESIDENCE		RW	Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility.

 

 

Claim Segment Questions	Check	Claim Billing/Claim Rebill If Situational, Payer Situation
This segment is always sent	X
This plan does not accept partial fills	X

 

 

Claim Segment Segment Identification (111 AM) = "07"		Claim Billing/Claim Rebill
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
455-EM	PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER	1 = Rx Billing	M
402-D2	PRESCRIPTION/SERVICE REFERENCE NUMBER	12 Bytes	M
456-EN	ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER	12 Bytes	RW	Required for partial fills. This value is the prescription number from the first partial fill.
436-E1	PRODUCT/SERVICE ID QUALIFIER	0 = Not specified 03 = National Drug Code (NDC)	M	00 must be submitted for compounds 03 for non-compound claims
407-D7	PRODUCT/SERVICE ID	NDC for non-compound claims "0" for compound claims	M
460-ET	QUANTITY PRESCRIBED	Metric Decimal Quantity	RW	Required when the transmission is for a Schedule II drug as defined in 21 CFR 1308.12 and per CMS-0055-F (Compliance Date 9/21/2020.) Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed
442-E7	QUANTITY DISPENSED	Metric Decimal Quantity	R
344-HF	QUANTITY INTENDED TO BE DISPENSED	Metric Decimal Quantity	RW	Required for partial fills. Metric decimal quantity of medication that would be dispensed for a full quantity.
403-D3	FILL NUMBER	0 = Original dispensing 1-5 = Refill number - Number of the replenishment	R
405-D5	DAYS SUPPLY		R
345-HG	DAYS SUPPLY INTENDED TO BE DISPENSED		RW	Required for partial fills. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity.
406-D6	COMPOUND CODE	1 = Not a Compound 2 = Compound	R
408-D8	DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE	0 = No Product Selection Indicated 1 = Substitution Not Allowed by Prescriber 8 = Substitution Allowed-Generic Drug Not Available in Marketplace 9 = Substitution Allowed by Prescriber but Plan Requests Brand	R	Values other than 0, 1, 08 and 09 will deny. The "Dispense as Written (DAW) Override Codes" table describes the valid scenarios allowable per DAW code.
343-HD	DISPENSING STATUS	P=Partial C=Complete	RW	Required for partial fills. "P" indicates the quantity dispensed is a partial fill. "C" indicates the completion of a partial fill.
414-DE	DATE PRESCRIPTION WRITTEN	CCYYMMDD	R
457-EP	ASSOCIATED PRESCRIPTION/SERVICE DATE	CCYYMMDD	RW	Required for partial fills. Date of service for the Associated Prescription/Service Reference Number (456-EN).
415-DF	NUMBER OF REFILLS AUTHORIZED	0 = No refills authorized 1-99 = Authorized Refill number - with 99 being as needed, refills unlimited	R
419-DJ	PRESCRIPTION ORIGIN CODE	1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile 5 = Pharmacy	R
354-NX	SUBMISSION CLARIFICATION CODE COUNT	Maximum count of 3	RW***	Required if field # 420-DK is sent
420-DK	SUBMISSION CLARIFICATION CODE		RW	8 = Process Compound For Approved Ingredients 9 = Encounters 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)).
308-C8	OTHER COVERAGE CODE		RW	Required for Coordination of Benefits. OCC 8 is not allowed. Health First Colorado is always the payer of last resort. Refer to the Other Coverage Code Quick sheet available in the Pharmacy Billing Procedures and Forms section of the Department's website.
600-28	UNIT OF MEASURE	EA = Each GM = Grams ML = Milliliters	R
481-DI	LEVEL OF SERVICE		RW
461-EU	PRIOR AUTHORIZATION TYPE CODE		RW
995-E2	ROUTE OF ADMINISTRATION	SNOMED CT Value	RW	Required when Rx is a compound.

 

 

Pricing Segment Questions	Check	Claim Billing/Claim Rebill If Situational, Payer Situation
This segment is always sent	X

 

 

Pricing Segment Segment Identification (111-AM) = "11"		Claim Billing/Claim Rebill
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
409-D9	INGREDIENT COST SUBMITTED		R
412-DC	DISPENSING FEE SUBMITTED		RW	Required if necessary as component of Gross Amount Due
426-DQ	USUAL AND CUSTOMARY CHARGE		R
430-DU	GROSS AMOUNT DUE		R
423-DN	BASIS OF COST DETERMINATION		RW	Imp Guide: Required if needed for receiver claim/encounter adjudication. 05 (Acquisition) or 08 (340B/Disproportionate Share Pricing/Public Health Service required when billing 340B transactions.

 

 

Prescriber Segment Questions	Check	Claim Billing/Claim Rebill If Situational, Payer Situation
This segment is always sent	X

 

 

Prescriber Segment Segment Identification (111-AM) = "03"		Claim Billing/Claim Rebill
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
466-EZ	PRESCRIBER ID QUALIFIER	01 = NPI 08 = State License # 12 = DEA	R
411-DB	PRESCRIBER ID	Prescriber's individual NPI, CO State License or DEA	R	Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 - Missing/Invalid Prescriber ID.

 

 

Coordination of Benefits/Other Payments Segment Questions	Check	Claim Billing/Claim Rebill If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Required only for secondary, tertiary, etc., claims.

 

 

Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = "05"		Claim Billing/Claim Rebill
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
337-4C	Coordination of Benefits/Other Payments Count	Maximum count of 9	RW
338-5C	Other Payer Coverage Type		RW
339-6C	OTHER PAYER ID QUALIFIER		RW	Required if Other Payer ID (Field # 340-7C) is used
340-7C	OTHER PAYER ID		RW	Required if COB segment is used. Other Payer ID = BIN of other payer.
443-E8	OTHER PAYER DATE		RW	Required if identification of the Other Payer Date is necessary for claim/encounter adjudication, CCYYMMDD
341-HB	OTHER PAYER AMOUNT PAID COUNT	Maximum count of 9	RW***	Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used.
342-HC	OTHER PAYER AMOUNT PAID QUALIFIER		RW	Required when there is payment from another source. Required if Other Payer Amount Paid (431-Dv) is used.
431-DV	OTHER PAYER AMOUNT PAID		RW	Required if other payer has approved payment for some/all of the billing. Required on all COB claims with Other Coverage Code of 2 or 4. OCC = 2 must submit >, $0.01, OCC = 4 must submit = 0.
471-5E	OTHER PAYER REJECT COUNT	Maximum count of 5.	RW***	Required if Other Payer Reject Code (472-6E) is used. Required on all COB claims with Other Coverage Code of 3.
472-6E	OTHER PAYER REJECT CODE		RW	Required on all COB claims with Other Coverage Code of 3
353-NR	OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT	Maximum count of 25	RW***	Required on all COB claims with Other Coverage Code of 2 or 4
351-NP	OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER		RW	Required if Other Payer patient Responsibility Amount (352-NQ) is submitted. Payer Requirement: Required if OCC = 4.  01 = Amount Applied to Periodic Deductible (517-FH) 02 = Amount Attributed to Product Selection/Brand Drug (134-UK)   03 = Amount Attributed to Sales Tax (523-FN) 04 = Amount Exceeding Periodic Benefit Maximum (520-FK) 05 = Amount of Copay (518-FI) 06 = Patient Pay  Amount (Deductible) (505-F5) 07 = Amount of Coinsurance (572-4U) 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 Formulary Selection (136-UN) 12 = Amount Attributed to Coverage Gap (137-UP) 13 = Amount Attributed to Processor Fee (571-NZ) *Note: Code 09 is a negative amount and is not a valid option for field 351-NP.
352-NQ	OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT		RW	Required for all COB claims with Other Coverage Code of 2 or 4. No blanks allowed

 

 

DUR/PPS Segment Questions	Check	Claim Billing/Claim Rebill If Situational, Payer Situation
This segment is always sent
This segment is situational	X	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.

 

 

DUR/PPS Segment Segment Identification (111-AM) = "08"		Claim Billing/Claim Rebill
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
473-7E	DUR/PPS CODE COUNTER	Maximum of 9 occurrences	RW***	Required if DUR/PPS Segment is used
439-E4	REASON FOR SERVICE CODE		RW***	Required when needed to communicate DUR information Allowed Values: DD = Drug-Drug Interaction ER = Early Refill HD = High Dose PG = Pregnancy
440-E5	PROFESSIONAL SERVICE CODE		RW***	Required when needed to communicate DUR information Allowed Values: MA = Medication Administration - use for vaccine M0 = Prescriber consulted P0 = Patient consulted R0 = Pharmacist consulted other source
441-E6	RESULT OF SERVICE CODE		RW***	Required when needed to communicate DUR information Allowed Values: 1A = Filled As Is, False Positive 1B = Filled Prescription As Is 1C = Filled, With Different Dose 1D = Filled, With Different Directions 1F = Filled, With Different Quantity 1G = Filled, With Prescriber Approval 2A = Prescription not filled 2B = Not filled, directions clarified

 

Compound Segment Questions	Check	Claim Billing/Claim Rebill If Situational, Payer Situation
This segment is always sent
This segment is situational	X	It is used for multi-ingredient prescriptions, when each ingredient is reported.

 

Compound Segment Segment Identification (111-AM) = "10"		Claim Billing/Claim Rebill
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
450-EF	COMPOUND DOSAGE FORM DESCRIPTION CODE		M
451-EG	COMPOUND DISPENSING UNIT FORM INDICATOR		M
447-EC	COMPOUND INGREDIENT COMPONENT COUNT		M	Colorado Pharmacy supports up to 25 ingredients
488-RE	COMPOUND PRODUCT ID QUALIFIER		M
489-TE	COMPOUND PRODUCT ID		M
448-ED	COMPOUND INGREDIENT QUANTITY		M
449-EE	COMPOUND INGREDIENT DRUG COST		M

 

**End of Request Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template**

 

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Response Claim Billing/Claim Rebill Payer Sheet Template

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

** Start of Response Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template**

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General Information

Payer Name: Magellan Rx Management	Date: 02/25/2017
Plan Name/Group Name: Colorado Medicaid	BIN: 018902	PCN: P303018902

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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.

 

Response Transaction Header Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
This segment is always sent	X

 

Response Transaction Header Segment		Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
102-A2	VERSION/RELEASE NUMBER		M
103-A3	TRANSACTION CODE		M
109-A9	TRANSACTION COUNT		M
501-F1	HEADER RESPONSE STATUS		M
202-B2	SERVICE PROVIDER ID QUALIFIER		M
201-B1	SERVICE PROVIDER ID		M
401-D1	DATE OF SERVICE		M

 

Response Message Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Sent if additional information is available from the payer/processor.

 

Response Message Segment Segment Identification (111-AM) = "20"		Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
504-F4	MESSAGE		RW	Required if text is needed for clarification or detail.

 

Response Insurance Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Sent if additional information is available from the payer/processor.

 

Response Insurance Segment Segment Identification (111-AM) = "25"		Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
301-C1	GROUP ID		RW	Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available.

 

Response Patient Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
This segment is always sent
This segment is situational

 

Response Patient Segment Segment Identification (111-AM) = "29"		Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
310-CA	PATIENT FIRST NAME		RW	Required if known.
311-CB	PATIENT LAST NAME		RW	Required if known.
304-C4	DATE OF BIRTH		RW	Required if known.

 

Response Status Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
This segment is always sent	X

 

Response Status Segment Segment Identification (111-AM) = "21"		Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
112-AN	TRANSACTION RESPONSE STATUS		M
503-F3	AUTHORIZATION NUMBER		RW	Required if needed to identify the transaction.
547-5F	APPROVED MESSAGE CODE COUNT		RW	Required if Approved Message Code (548-6F) is used.
548-6F	APPROVED MESSAGE CODE		RW	Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity.
130-UF	ADDITIONAL MESSAGE INFORMATION COUNT		RW	Required if Additional Message Information (526-FQ) is used.
132-UH	ADDITIONAL MESSAGE INFORMATION QUALIFIER		RW	Required if Additional Message Information (526-FQ) is used.
526-FQ	ADDITIONAL MESSAGE INFORMATION		RW	Required when additional text is needed for clarification or detail.
131-UG	ADDITIONAL MESSAGE INFORMATION CONTINUITY		RW	Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F	HELP DESK PHONE NUMBER QUALIFIER		RW	Required if Help Desk Phone Number (550-8F) is used.
550-8F	HELP DESK PHONE NUMBER		RW	Required if needed to provide a support telephone number to the receiver.

 

Response Claim Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
This segment is always sent	X

 

Response Claim Segment Segment Identification (111-AM) = "22"		Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
455-EM	PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER		M
402-D2	PRESCRIPTION/SERVICE REFERENCE NUMBER		M

 

Response Pricing Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
This segment is always sent	X

 

Response Pricing Segment Segment Identification (111-AM) = "23"		Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
505-F5	PATIENT PAY AMOUNT		R
506-F6	INGREDIENT COST PAID		R
507-F7	DISPENSING FEE PAID		RW	Required if this value is used to arrive at the final reimbursement.
557-AV	TAX EXEMPT INDICATOR		RW	Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing.
521-FL	INCENTIVE AMOUNT PAID		RW	Required if this value is used to arrive at the final reimbursement. Required if Incentive Amount Submitted (438-E3) is greater than zero (0).
563-J2	OTHER AMOUNT PAID COUNT		RW	Imp Guide: Required if Other Amount Paid (565-J4) is used.
564-J3	OTHER AMOUNT PAID QUALIFIER		RW	Imp Guide: Required if Other Amount Paid (565-J4) is used.
565-J4	OTHER AMOUNT PAID		RW	Required if this value is used to arrive at the final reimbursement. Required if Other Amount Claimed Submitted (480-H9) is greater than zero (0).
566-J5	OTHER PAYER AMOUNT RECOGNIZED		RW	Required if this value is used to arrive at the final reimbursement. Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported.
509-F9	TOTAL AMOUNT PAID		R
522-FM	BASIS OF REIMBURSEMENT DETERMINATION		RW	Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Required if Basis of Cost Determination (432-DN) is submitted on billing.
512-FC	ACCUMULATED DEDUCTIBLE AMOUNT		RW	Provided for informational purposes only.
513-FD	REMAINING DEDUCTIBLE AMOUNT		RW	Provided for informational purposes only.
514-FE	REMAINING BENEFIT AMOUNT		RW	Provided for informational purposes only.
517-FH	AMOUNT APPLIED TO PERIODIC DEDUCTIBLE		RW	Required if Patient Pay Amount (505-F5) includes deductible
518-FI	AMOUNT OF COPAY		RW	Required if Patient Pay Amount (505-F5) includes co-pay as patient financial responsibility.
520-FK	AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM		RW	Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum.
572-4U	AMOUNT OF COINSURANCE		RW	Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility.
128-UC	SPENDING ACCOUNT AMOUNT REMAINING		RW	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.
129-UD	HEALTH PLAN-FUNDED ASSISTANCE AMOUNT		RW	Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero.

 

Response DUR/PPS Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Sent when DUR intervention is encountered during claim processing.

 

Response DUR/PPS Segment Segment Identification (111-AM) = "24"		Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
567-J6	DUR/PPS RESPONSE CODE COUNTER		RW	Required if Reason for Service Code (439-E4) is used.
439-E4	REASON FOR SERVICE CODE		RW	Required if utilization conflict is detected.
528-FS	CLINICAL SIGNIFICANCE CODE		RW	Required if needed to supply additional information for the utilization conflict.
529-FT	OTHER PHARMACY INDICATOR		RW	Required if needed to supply additional information for the utilization conflict.
530-FU	PREVIOUS DATE OF FILL		RW	Required if needed to supply additional information for the utilization conflict. Required if Quantity of Previous Fill (531-FV) is used.
531-FV	QUANTITY OF PREVIOUS FILL		RW	Required if needed to supply additional information for the utilization conflict. Required if Previous Date Of Fill (530-FU) is used.
532-FW	DATABASE INDICATOR		RW	Required if needed to supply additional information for the utilization conflict.
533-FX	OTHER PRESCRIBER INDICATOR		RW	Required if needed to supply additional information for the utilization conflict.
544-FY	DUR FREE TEXT MESSAGE		RW	Required if needed to supply additional information for the utilization conflict.
570-NS	DUR ADDITIONAL TEXT		RW	Required if needed to supply additional information for the utilization conflict.

 

Response Coordination of Benefits/Other Payers Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Sent when Other Health Insurance (OHI) is encountered during claims processing.

 

Response Coordination of Benefits/Other Payers Segment Segment Identification (111-AM) = "28"		Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid)
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
355-NT	OTHER PAYER ID COUNT		RW
338-5C	OTHER PAYER COVERAGE TYPE		RW
339-6C	OTHER PAYER ID QUALIFIER		RW	Required if Other Payer ID (340-7C) is used.
340-7C	OTHER PAYER ID		RW	Required if other insurance information is available for coordination of benefits.
991-MH	OTHER PAYER PROCESSOR CONTROL NUMBER		RW	Required if other insurance information is available for coordination of benefits.
356-NU	OTHER PAYER CARDHOLDER ID		RW	Required if other insurance information is available for coordination of benefits.
992-MJ	OTHER PAYER GROUP ID		RW	Required if other insurance information is available for coordination of benefits.
142-UV	OTHER PAYER PERSON CODE		RW	Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer.
127-UB	OTHER PAYER HELP DESK PHONE NUMBER		RW	Required if needed to provide a support telephone number of the other payer to the receiver.
143-UW	OTHER PAYER PATIENT RELATIONSHIP CODE		RW	Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer.

 

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Claim Billing/Claim Rebill Accepted/Rejected Response

 

Response Transaction Header Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
This segment is always sent	X

 

Response Transaction Header Segment		Claim Billing/Claim Rebill Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
102-A2	VERSION/RELEASE NUMBER		M
103-A3	TRANSACTION CODE		M
109-A9	TRANSACTION COUNT		M
501-F1	HEADER RESPONSE STATUS		M
202-B2	SERVICE PROVIDER ID QUALIFIER		M
201-B1	SERVICE PROVIDER ID		M
401-D1	DATE OF SERVICE		M

 

Response Transaction Header Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Required if text is needed for clarification or detail.

 

Response Message Segment Segment Identification (111-AM) = "20"		Claim Billing/Claim Rebill Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
504-F4	MESSAGE		RW

 

Response Insurance Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
This segment is always sent	X
This segment is situational

 

Response Insurance Segment Segment Identification (111-AM) = "25"		Claim Billing/Claim Rebill Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
301-C1	GROUP ID		R	Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. Required to identify the actual group that was used when multiple group coverage exist.
302-C2	CARDHOLDER ID		RW	Required if the identification to be used in future transactions is different than what was submitted on the request.

 

Response Patient Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Sent when known by plan

 

Response Patient Segment Segment Identification (111-AM) = "29"		Claim Billing/Claim Rebill Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
310-CA	PATIENT FIRST NAME		RW	Required if known.
311-CB	PATIENT LAST NAME		RW	Required if known.
304-C4	DATE OF BIRTH		RW	Required if known.

 

Response Status Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
This segment is always sent	X

 

Response Status Segment Segment Identification (111-AM) = "21"		Claim Billing/Claim Rebill Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
112-AN	TRANSACTION RESPONSE STATUS		M
503-F3	AUTHORIZATION NUMBER			Required if needed to identify the transaction.
510-FA	REJECT COUNT		R
511-FB	REJECT CODE		R
546-4F	REJECT FIELD OCCURRENCE INDICATOR		RW	Required if a repeating field is in error, to identify repeating field occurrence.
130-UF	ADDITIONAL MESSAGE INFORMATION COUNT		RW	Required if Additional Message Information (526-FQ) is used.
132-UH	ADDITIONAL MESSAGE INFORMATION QUALIFIER		RW	Required if Additional Message Information (526-FQ) is used.
526-FQ	ADDITIONAL MESSAGE INFORMATION		RW	Required when additional text is needed for clarification or detail.
131-UG	ADDITIONAL MESSAGE INFORMATION CONTINUITY		RW	Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F	HELP DESK PHONE NUMBER QUALIFIER		RW	Required if Help Desk Phone Number (550-8F) is used.
550-8F	HELP DESK PHONE NUMBER		RW	Required if needed to provide a support telephone number to the receiver.

 

Response Claim Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
This segment is always sent	X

 

Response Claim Segment Segment Identification (111-AM) = "22"		Claim Billing/Claim Rebill Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
455-EM	PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER		M	Imp Guide: For Transaction Code of "B1," in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).
402-D2	PRESCRIPTION/SERVICE REFERENCE NUMBER		M

 

Response DUR/PPS Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Sent when DUR intervention is encountered during claim adjudication.

 

Response DUR/PPS Segment Segment Identification (111-AM) = "24"		Claim Billing/Claim Rebill Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
567-J6	DUR/PPS RESPONSE CODE COUNTER	Maximum 9 occurrences supported.	RW	Required if Reason for Service Code (439-E4) is used.
439-E4	REASON FOR SERVICE CODE		RW	Required if utilization conflict is detected.
528-FS	CLINICAL SIGNIFICANCE CODE		RW	Required if needed to supply additional information for the utilization conflict.
529-FT	OTHER PHARMACY INDICATOR		RW	Required if needed to supply additional information for the utilization conflict.
530-FU	PREVIOUS DATE OF FILL		RW	Required if needed to supply additional information for the utilization conflict. Required if Quantity of Previous Fill (531-FV) is used.
531-FV	QUANTITY OF PREVIOUS FILL		RW	Required if needed to supply additional information for the utilization conflict. Required if Previous Date of Fill (530-FU) is used.
532-FW	DATABASE INDICATOR		RW	Required if needed to supply additional information for the utilization conflict.
533-FX	OTHER PRESCRIBER INDICATOR		RW	Required if needed to supply additional information for the utilization conflict.
544-FY	DUR FREE TEXT MESSAGE		RW	Required if needed to supply additional information for the utilization conflict.
570-NS	DUR ADDITIONAL TEXT		RW	Required if needed to supply additional information for the utilization conflict.

 

Response Prior Authorization Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Sent when claim adjudication outcome requires subsequent PA number for payment

 

Response Prior Authorization Segment Segment Identification (111-AM) = "26"		Claim Billing/Claim Rebill Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
498-PY	PRIOR AUTHORIZATION NUMBER-ASSIGNED		RW	Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim.

 

Response Coordination of Benefits/Other Payers Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Sent when Other Health Insurance (OHI) is encountered during claim processing.

 

Response Coordination of Benefits/Other Payers Segment Segment Identification (111-AM) = "28"		Claim Billing/Claim Rebill Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
355-NT	OTHER PAYER ID COUNT		RW
338-5C	OTHER PAYER COVERAGE TYPE		RW
339-6C	OTHER PAYER ID QUALIFIER		RW	Required if Other Payer ID (340-7C) is used.
340-7C	OTHER PAYER ID		RW	Required if other insurance information is available for coordination of benefits.
991-MH	OTHER PAYER PROCESSOR CONTROL NUMBER		RW	Required if other insurance information is available for coordination of benefits.
356-NU	OTHER PAYER CARDHOLDER ID		RW	Required if other insurance information is available for coordination of benefits.
992-MJ	OTHER PAYER GROUP ID		RW	Required if other insurance information is available for coordination of benefits.
142-UV	OTHER PAYER PERSON CODE		RW	Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer.
127-UB	OTHER PAYER HELP DESK PHONE NUMBER		RW	Required if needed to provide a support telephone number of the other payer to the receiver.
143-UW	OTHER PAYER PATIENT RELATIONSHIP CODE		RW	Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer.

 

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Claim Billing/Claim Rebill Rejected/Rejected Response

 

Response Transaction Header Segment Questions	Check	Claim Billing/Claim Rebill Rejected/Rejected If Situational, Payer Situation
This segment is always sent	X

 

Response Transaction Header Segment		Claim Billing/Claim Rebill Rejected/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
102-A2	VERSION/RELEASE NUMBER		M
103-A3	TRANSACTION CODE		M
109-A9	TRANSACTION COUNT		M
501-F1	HEADER RESPONSE STATUS		M
202-B2	SERVICE PROVIDER ID QUALIFIER		M
201-B1	SERVICE PROVIDER ID		M
401-D1	DATE OF SERVICE		M

 

Response Message Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
This segment is always sent
This segment is situational	X

 

Response Message Segment Segment Identification (111-AM) = "20"		Claim Billing/Claim Rebill Rejected/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
504-F4	MESSAGE		RW	Required if text is needed for clarification or detail.

 

Response Status Segment Questions	Check	Claim Billing/Claim Rebill Accepted/Rejected If Situational, Payer Situation
This segment is always sent	X

 

Response Status Segment Segment Identification (111-AM) = "21"		Claim Billing/Claim Rebill Rejected/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
112-AN	TRANSACTION RESPONSE STATUS		M
503-F3	AUTHORIZATION NUMBER		RW	Required if needed to identify the transaction.
510-FA	REJECT COUNT		R
511-FB	REJECT CODE		R
546-4F	REJECT FIELD OCCURRENCE INDICATOR		RW	Required if a repeating field is in error, to identify repeating field occurrence.
130-UF	ADDITIONAL MESSAGE INFORMATION COUNT		RW	Required if Additional Message Information (526-FQ) is used.
132-UH	ADDITIONAL MESSAGE INFORMATION QUALIFIER		RW	Required if Additional Message Information (526-FQ) is used.
526-FQ	ADDITIONAL MESSAGE INFORMATION		RW	Required when additional text is needed for clarification or detail.
131-UG	ADDITIONAL MESSAGE INFORMATION CONTINUITY		RW	Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F	HELP DESK PHONE NUMBER QUALIFIER		RW	Required if Help Desk Phone Number (550-8F) is used.
550-8F	HELP DESK PHONE NUMBER		RW	Required if needed to provide a support telephone number to the receiver.

 

 

** End of Response Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template**

 

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NCPDP Version D.0 Claim Reversal Template

Request Claim Reversal Payer Sheet Template

 

** Start of Request Claim Reversal (B2) Payer Sheet Template**

 

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General Information

Payer Name: Magellan Rx Management	Date: 02/25/2017
Plan Name/Group Name: Colorado Medicaid	BIN: 018902	PCN: P303018902

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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.

Transaction Header Segment Questions	Check	Claim Reversal If Situational, Payer Situation
This segment is always sent	X
Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Payer Issued	X

 

Transaction Header Segment		Claim Reversal
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
101-A1	BIN NUMBER	018902	M
102-A2	VERSION/RELEASE NUMBER		M
103-A3	TRANSACTION CODE		M
104-A4	PROCESSOR CONTROL NUMBER	P303018902	M
109-A9	TRANSACTION COUNT		M
202-B2	SERVICE PROVIDER ID QUALIFIER		M
201-B1	SERVICE PROVIDER ID		M
401-D1	DATE OF SERVICE		M
110-AK	SOFTWARE VENDOR/CERTIFICATION ID	This will be provided by the provider's software vendor	M	If no number is supplied, populate with zeros

 

 

Insurance Segment Questions	Check	Claim Reversal If Situational, Payer Situation
This segment is always sent	X
This segment is situational

 

 

Insurance Segment Segment Identification (111-AM) = "04"		Claim Reversal
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
302-C2	CARDHOLDER ID		M
301-C1	GROUP ID		RW	Required if needed to match the reversal to the original billing transaction.
306-C6	PATIENT RELATIONSHIP CODE		R

 

 

Claim Segment Questions	Check	Claim Reversal If Situational, Payer Situation
This segment is always sent	X

 

 

Claim Segment Segment Identification (111-AM) = "07"		Claim Reversal
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
455-EM	PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER		M
402-D2	PRESCRIPTION/SERVICE REFERENCE NUMBER		M
436-E1	PRODUCT/SERVICE ID QUALIFIER		M
407-D7	PRODUCT/SERVICE ID		M
403-D3	FILL NUMBER		R	Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (402-D2) occur on the same day.
308-C8	OTHER COVERAGE CODE		RW	Required if needed by receiver to match the claim that is being reversed.

 

 

Pricing Segment Questions	Check	Claim Reversal If Situational, Payer Situation
This segment is always sent
This segment is situational	X

 

 

Pricing Segment Segment Identification (111-AM) = "11"		Claim Reversal
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
438-E3	INCENTIVE AMOUNT SUBMITTED		RW	Required if this field could result in contractually agreed upon payment.
430-DU	GROSS AMOUNT DUE		RW	Required if this field could result in contractually agreed upon payment.

 

 

Coordination of Benefits/Other Payments Segment Questions	Check	Claim Reversal If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Required only for secondary, tertiary, etc., claims.
Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs)	X	OCC codes 0, 1, 2, 3, and 4 Supported (no co-pay only billing allowed)

 

 

Coordination of Benefits/Other Payments Segment Segment Identification (111-AM) = "05"		Claim Reversal
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
337-4C	COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT		RW
338-5C	Other Payer Coverage Type		RW
339-6C	OTHER PAYER ID QUALIFIER		RW	Required if Other Payer ID (Field # 340-7C) is used
340-7C	OTHER PAYER ID		RW	Required if COB segment is used
443-E8	OTHER PAYER DATE		RW	Required if identification of the Other Payer Date is necessary for claim/encounter adjudication.
341-HB	OTHER PAYER AMOUNT PAID COUNT		RW	Required if Other Payer Amount Paid Qualifier (342-HC) is used.
342-HC	OTHER PAYER AMOUNT PAID QUALIFIER		RW	Required when there is payment from another source. Required on all COB claims with Other Coverage Code of 2 "07" is the only accepted value.
431-DV	OTHER PAYER AMOUNT PAID		RW	Required if other payer has approved payment for some/all of the billing.
471-5E	OTHER PAYER REJECT COUNT		RW***	Required on all COB claims with Other Coverage Code of 3.
472-6E	OTHER PAYER REJECT CODE		RW	Required on all COB claims with Other Coverage Code of 3
353-NR	OTHER PAYER - PATIENT RESPONSIBILITY AMOUNT COUNT		R	Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used
351-NP	OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFER		R	Required if Other Payer-Patient Responsibility Amount (352-NQ) is used352-NQ
352-NQ	OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT		R	Required OCC = 2 or 4

 

** End of Request Claim Reversal (B2) Payer Sheet Template**

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Response Claim Reversal Payer Sheet Template

Claim Reversal Accepted/Approved Response

** Start of Claim Reversal Response (B2) Payer Sheet Template**

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General Information

Payer Name: Magellan Rx Management	Date: 02/25/2017
Plan Name/Group Name: Colorado Medicaid	BIN: 018902	PCN: P303018902

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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.

Response Transaction Header Segment Questions	Check	Claim Reversal - Accepted/Approved If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Required only for secondary, tertiary, etc., claims.

Response Transaction Header Segment		Claim Reversal - Accepted/Approved
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
102-A2	VERSION/RELEASE NUMBER		M
103-A3	TRANSACTION CODE		M
109-A9	TRANSACTION COUNT		M
501-F1	HEADER RESPONSE STATUS		M
202-B2	SERVICE PROVIDER ID QUALIFIER		M
201-B1	SERVICE PROVIDER ID		M
401-D1	DATE OF SERVICE		M

 

Response Message Segment Questions	Check	Claim Reversal - Accepted/Approved If Situational, Payer Situation
This segment is always sent
This segment is situational	X

 

 

Response Message Segment Segment Identification (111-AM) = "20"		Claim Reversal - Accepted/Approved
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
504-F4	MESSAGE		RW	Required if text is needed for clarification or detail.

 

 

Response Status Segment Questions	Check	Claim Reversal - Accepted/Approved If Situational, Payer Situation
This segment is always sent

 

 

Response Status Segment Segment Identification (111-AM) = "21"		Claim Reversal - Accepted/Approved
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
112-AN	TRANSACTION RESPONSE STATUS		M
503-F3	AUTHORIZATION NUMBER		RW	Required if needed to identify the transaction.
547-5F	APPROVED MESSAGE CODE COUNT		RW	Required if Approved Message Code (548-6F) is used.
548-6F	APPROVED MESSAGE CODE		RW	Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity.
130-UF	ADDITIONAL MESSAGE INFORMATION COUNT		RW	Required if Additional Message Information (526-FQ) is used.
132-UH	ADDITIONAL MESSAGE INFORMATION QUALIFIER		RW	Required if Additional Message Information (526-FQ) is used.
526-FQ	ADDITIONAL MESSAGE INFORMATION		RW	Required when additional text is needed for clarification or detail.
131-UG	ADDITIONAL MESSAGE INFORMATION CONTINUITY		RW	Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
49-7F	HELP DESK PHONE NUMBER QUALIFIER		RW	Required if Help Desk Phone Number (550-8F) is used.
550-8F	HELP DESK PHONE NUMBER		RW	Required if needed to provide a support telephone number to the receiver.

 

 

Response Claim Segment Questions	Check	Claim Reversal - Accepted/Approved If Situational, Payer Situation
This segment is always sent	X

 

 

Response Claim Segment Segment Identification (111-AM) = "22"		Claim Reversal - Accepted/Approved
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
455-EM	PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER		M	For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).
402-D2	PRESCRIPTION/SERVICE REFERENCE NUMBER		M

 

Response Pricing Segment Questions	Check	Claim Reversal - Accepted/Approved If Situational, Payer Situation
This segment is always sent
This segment is situational	X	Sent if reversal results in generation of pricing detail.

 

Response Pricing Segment Segment Identification (111-AM) = "22"		Claim Reversal - Accepted/Approved
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
521-FL	INCENTIVE AMOUNT PAID		RW	Required if this field is reporting a contractually agreed upon payment.
509-F9	TOTAL AMOUNT PAID		RW	Required if any other payment fields sent by the sender.

 

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Claim Reversal Accepted/Rejected Response

Response Transaction Header Segment Questions	Check	Claim Reversal - Accepted/Approved If Situational, Payer Situation
This segment is always sent	X

 

Response Transaction Header Segment		Claim Reversal - Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
102-A2	VERSION/RELEASE NUMBER		M
103-A3	TRANSACTION CODE		M
109-A9	TRANSACTION COUNT		M
501-F1	HEADER RESPONSE STATUS		M
202-B2	SERVICE PROVIDER ID QUALIFIER		M
201-B1	SERVICE PROVIDER ID		M
401-D1	DATE OF SERVICE		M

 

 

Response Message Segment Questions	Check	Claim Reversal - Accepted/Rejected If Situational, Payer Situation
This segment is always sent
This segment is situational	X

 

 

Response Message Segment Segment Identification (111-AM) = "20"		Claim Reversal - Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
504-F4	MESSAGE		RW	Required if text is needed for clarification or detail.

 

 

Response Status Segment Questions	Check	Claim Reversal - Accepted/Rejected If Situational, Payer Situation
This segment is always sent	X

 

 

Response Status Segment Segment Identification (111-AM) = "21"		Claim Reversal - Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
112-AN	TRANSACTION RESPONSE STATUS		M
503-F3	AUTHORIZATION NUMBER		R
510-FA	REJECT COUNT		R
511-FB	REJECT CODE		R
546-4F	REJECT FIELD OCCURRENCE INDICATOR		RW	Required if a repeating field is in error, to identify repeating field occurrence.
130-UF	ADDITIONAL MESSAGE INFORMATION COUNT		RW	Required if Additional Message Information (526-FQ) is used.
132-UH	ADDITIONAL MESSAGE INFORMATION QUALIFIER		RW	Required if Additional Message Information (526-FQ) is used.
526-FQ	ADDITIONAL MESSAGE INFORMATION		RW	Required when additional text is needed for clarification or detail.
131-UG	ADDITIONAL MESSAGE INFORMATION CONTINUITY		RW	Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F	HELP DESK PHONE NUMBER QUALIFIER		RW	Required if Help Desk Phone Number (550-8F) is used.
550-8F	HELP DESK PHONE NUMBER		RW	Required if needed to provide a support telephone number to the receiver.

 

 

Response Claim Segment Questions	Check	Claim Reversal - Accepted/Rejected If Situational, Payer Situation
This segment is always sent	X

 

 

Response Claim Segment Segment Identification (111-AM) = "22"		Claim Reversal - Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
455-EM	PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER		M	For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).
402-D2	PRESCRIPTION/SERVICE REFERENCE NUMBER		M

 

 

Coordination of Benefits/Other Payments Segment Questions	Check	Claim Reversal If Situational, Payer Situation
This segment is always sent
This segment is situational	X

 

 

Coordination of Benefits/Other Payments Segment Identification (111-AM) = "05"		Claim Reversal - Accepted/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
337-4C	COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT		RW
338-5C	OTHER PAYER COVERAGE TYPE		RW

 

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Claim Reversal Rejected/Rejected Response

Response Transaction Header Segment Questions	Check	Claim Reversal - Rejected/Rejected If Situational, Payer Situation
This segment is always sent	X

 

Response Transaction Header Segment		Claim Reversal - Rejected/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
102-A2	VERSION/RELEASE NUMBER		M
103-A3	TRANSACTION CODE		M
109-A9	TRANSACTION COUNT		M
501-F1	HEADER RESPONSE STATUS		M
202-B2	SERVICE PROVIDER ID QUALIFIER		M
201-B1	SERVICE PROVIDER ID		M
401-D1	DATE OF SERVICE		M

 

 

Response Message Segment Questions	Check	Claim Reversal - Rejected/Rejected If Situational, Payer Situation
This segment is always sent
This segment is situational	X

 

 

Response Message Segment Segment Identification (111-AM) = "20"		Claim Reversal - Rejected/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
504-F4	MESSAGE		RW	Imp. Guide: Required if text is needed for clarification or detail. Payer Requirement: Same as Imp Guide

 

 

 

Response Status Segment Questions	Check	Claim Reversal - Rejected/Rejected If Situational, Payer Situation
This segment is always sent	X

 

 

 

Response Status Segment Segment Identification (111-AM) = "21"		Claim Reversal - Rejected/Rejected
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situations
112-AN	TRANSACTION RESPONSE STATUS		M
503-F3	AUTHORIZATION NUMBER		R
510-FA	REJECT COUNT		R
511-FB	REJECT CODE		R
546-4F	REJECT FIELD OCCURRENCE INDICATOR		RW	Required if a repeating field is in error, to identify repeating field occurrence.
130-UF	ADDITIONAL MESSAGE INFORMATION COUNT		RW	Required if Additional Message Information (526-FQ) is used.
132-UH	ADDITIONAL MESSAGE INFORMATION QUALIFIER		RW	Required if Additional Message Information (526-FQ) is used.
526-FQ	ADDITIONAL MESSAGE INFORMATION		RW	Required when additional text is needed for clarification or detail.
131-UG	ADDITIONAL MESSAGE INFORMATION CONTINUITY		RW	Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F	HELP DESK PHONE NUMBER QUALIFIER		RW	Required if Help Desk Phone Number (550-8F) is used.
550-8F	HELP DESK PHONE NUMBER		RW	Required if needed to provide a support telephone number to the receiver.

 

 

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Revision History

Revision date	Additions/Changes
08/26/2016	Updates made throughout related to the POS implementation under Magellan Rx Management.
09/26/2016	Updates made throughout related to the POS implementation under Magellan Rx Management.
01/05/2017	Updates made to DAW requirements
02/03/2017	Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. Update to URL posted under Restricted Products section per Cathy T. request.
02/03/2017	Medication Requiring PAR - Update to Over-the-counter products. Refill Too Soon Policy - Update to refill too soon policy for Synagis. Restricted Products - updated to DESI coverage requirements. Benzodiazepines removed from coverage list. Billing Information - gaps or spacing removed. Instructions for Completing the Pharmacy Claim Form - Client's Medicaid ID field length changed to 7-characters D.0 General Information - updated based on new POS go-live date. Cover Page - updated
02/08/2017	Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier.
05/23/2017	Updated Lost/Stolen/Damaged/Vacation Prescriptions section - police report is no longer required for Stolen Medications, Updated DAW chart with the following note for DAW 9: Note: For products that are Brand Name Required, DAW 9 will be allowed, Added B2 to the Transactions Supported Chart, Added the following to 351-NP Other Payer Patient Responsibility Amount Qualifier: 06 = Patient Pay Applied to Amount (only if Periodic Prior Payer was still Deductible in NCPDP version
08/28/2017	PAR Process: Updated notification letter section RTS Policy: Updated accumulation language DAW 8: Updated section that applies to drug list 340B Claims Processing: Added chart for values Single Agent Antihistamines: Combination product with decongestant language added Timely Filing: Remittance Advice (RA) language updated Appealing: Fax number added to section Reuse of Rx Numbers: New section added
10/13/2017	Partial Fills and/or Prescription: Updated partial fill criteria 340B Claims Processing: Updated acquisition cost value
11/8/2017	Updated contact information on page 15, to include Magellan's helpdesk info
11/20/2017	Update verbiage in Co-pay section
08/22/2018	Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. DAW Codes: Updated "Dispense as Written (DAW) Override Code" table and updated payor sheets to reflect allowable DAW codes. Green highlighting: Removed highlighting throughout document on previous new additions.
3/27/2020	Updated verbiage in Counseling section
5/6/2020	Added Temporary COVID section, updated Provider Web Portal link
6/4/2020	Converted into web page.
7/1/2020	Updated verbiage to include the NCPDP D.0 guidelines for field 460-ET
7/8/2020	Updated DAW Codes: Updated Dispense as Written (DAW) Override Code table
8/20/2020	Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions.
9/25/2020	Updated COVID Early Refill Policy
11/17/2020	Updated Partial Fill Section to read Incremental Fills and/or Prescription Splitting
11/16/2021	Updated Quantity Prescribed valid value policy
1/6/2022	Updated the diagnosis codes in COVID-19 zero copay section. Effective 10/22/2021
1/6/2022	Updated policy for Quantity Limit overrides in COVID-19 section. Effective 10/22/2021
1/18/2022	Corrected formatting error; replaced "√ò" with numeric "0"
5/10/2022	Updated “Co-pay Exclusions” section and inserted new “Family Planning and Family Planning Related Services” section. Effective 7/1/2022 Updated “Temporary COVID-19 Policy and Billing Changes”
8/29/2022	Added Real Time Prior Authorization via EHR to PAR Process
10/15/2022	Updated to reflect billing changes to family planning and family planning-related services
10/19/2022	Updated family planning-related section for clarity
11/30/2022	Added primary insurance clarification to PAR Process and max day supply clarification to Dispensing Requirements
12/2/2022	Added record maintenance requirements under Counseling, Retention of Records, and Signature Requirements
12/29/2022	Removed requirement for providers to obtain a new override each fill for TPL/COB prior authorizations
2/17/2023	Updated qualifier codes accepted in COB/ Other Payments under Claim Billing
5/12/2023	Removed portions from “Temporary COVID-19 Policy and Billing Changes” which are no longer in effect due to the end of the PHE occurring on 5/11/2023. Updated “Counseling” section.
7/1/2023	Updated Co-Pay section to reflect removal of pharmacy co-pays for members. Replaced Family Planning and Family-Planning sections with Family Planning Pharmacy Billing for Special Populations. Updated Mail Order section for clarity on Department policy. Added clarification to DAW Code 8.
9/1/2023	Added policy for prescription replacement due to natural disaster.