It is used for multi-ingredient prescriptions, when each ingredient is reported. Effective 10/22/2021, Corrected formatting error; replaced "" with numeric "0", Added Real Time Prior Authorization via EHR to PAR Process, Updated to reflect billing changes to family planning and family planning-related services, Updated family planning-related section for clarity, Added primary insurance clarification to PAR Process and max day supply clarification to Dispensing Requirements, Added record maintenance requirements under Counseling, Retention of Records, and Signature Requirements, Removed requirement for providers to obtain a new override each fill for TPL/COB prior authorizations, Updated qualifier codes accepted in COB/ Other Payments under Claim Billing, Proposed rendering provider (if identified on the PAR), Non-preferred agents subject to the Preferred Drug List (PDL), Preferred agents with clinical criteria attached to the medication and all non-preferred agents subject to the Preferred Drug List (PDL) Over-the-counter (OTC) drugs that are not a regular Health First Colorado program benefit, Intravenous (IV) solutions with clinical criteria attached to the medication, Total Parenteral Nutrition (TPN) therapy and drugs, Significance of impact on the health of the Health First Colorado program population, Required monitoring of prescribing protocols to protect both the long-term efficacy of the drug and the public health, Potential for, or a history of, drug diversion and other illegal utilization, Appearance of the Health First Colorado program usage in amounts inconsistent with non- medical assistance program usage patterns, after adjusting for population characteristics, Clinical safety and efficacy compared to other drugs in that class of medications, Availability of more cost-effective comparable alternatives, Procedures where inappropriate utilization has been reported in medical literature, Performing auditing services with constant review on drug utilization. Medication Requiring PAR - Update to Over-the-counter products. Please contact the Pharmacy Support Center with questions. Maternal, Child and Reproductive Health billing manual web page. Payer/Carrier BIN/PCN Date Available Vendor Certification ID 4D d/b/a Medtipster 610209/05460000 Current 601DN30Y Adjudicated Marketing 600428/05080000 Current 601DN30Y Alaska Medicaid 009661 Current 091511D002 Information on the Food Assistance Program, eligibility requirements, and other food resources. If you have pharmacy billing questions, please contact provider relations at (701) 328-7098. Required when there is payment from another source. Notification of PAR approval or denial is sent to each of the following parties: In addition to stating whether the PAR has been approved or denied, a PAR denial notification letter is sent to members. Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. Incremental and subsequent fills may not be transferred from one pharmacy to another. Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. Prescription Exception Requests. A PAR is only necessary if an ingredient in the compound is subject to prior authorization. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. All member ID numbers will be the same for the beneficiary whether they are enrolled in a health plan or in NC Medicaid Direct. Vision and hearing care. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. In order to participate in the Discount . Additionally, all providers entering 340B claims must be registered and active with HRSA. 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. BIN: 610084 PCN: DRMTUA01 = Test (after 1/1/2012) Processor: Conduent Effective as of: June 1, 2017 NCPDP Telecommunication Standard Version/Release D. 0 NCPDP Data Dictionary Version Date: April 2017 NCPDP External Code List Version Date: April 2017 Updated: March 23, 2021 - - Provider Relations: (800) 365-4944 - - Required if needed by receiver to match the claim that is being reversed. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. Signature requirements are temporarily waived for Member Counseling and Proof of Delivery. These medications (e.g., Paxlovid) still need to be billed to Colorado Medicaid, even though they are free of cost, and the claim requirements for billing free medications is outlined below: The Health First Colorado program uses the National Council on Prescription Drug Programs (NCPDP) electronic format and the Pharmacy Claim Form (PCF) to submit prescription drug claims. The use of inaccurate or false information can result in the reversal of claims. To learn more, view our full privacy policy. This will allow the pharmacist to determine if the medication was prescribed in relation to a family planning visit (e.g., tobacco cessation, UTI and STI/STD medications). 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. Medicaid Managed Care BIN, PCN, and Group 1/1/2019 through 12/31/2019 (pharmacy services carved out of managed care starting 1/1/2020) BIN 610011, PCN IRX, Group SHNNDMEDI If you have pharmacy questions, you may email them to dhsmed@nd.gov. BIN: 610164: PCN: DRWVPROD: Questions regarding claims processing should be directed to the Medicaid's Fiscal Agent's POS Pharmacy Help Desk at 1.888.483.0801. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. false false Insertion sort: Split the input into item 1 (which might not be the smallest) and all the rest of the list. Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. Enrolled Medicaid fee-for-service (FFS) members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies. BIN - 800008 PCN - not required Group - not required > SelectHealth Advantage (Medicare Part D) BIN - 015938 PCN - 7463 Group - UT/ID = U1000009; NV Intermountain = U1000011 > SelectHealth Community Care (Utah State Medicaid) BIN - 800008 PCN - 606 Group - not required Please Note: Physician administered (J-Code) drugs that are not listed on the Medicaid Pharmacy List of Reimbursable Drugs and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) as listed in sections 4.4, 4.5, 4.6, and 4.7 of the Durable Medical Equipment, Prosthetics and Supplies Manual are not subject to the carve-out. Plan PBM Phone BIN PCN Group OHA (Fee-for-Service or "Open Card") 888-202-2126 . Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. A 7.5 percent tolerance is allowed between fills for Synagis. A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. This requirement stems from the Social Security Act, 42 U.S.C. The following lists the segments and fields in a Claim Billing Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. The Helpdesk is available 24 hours a day, seven days a week. 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) For more information on the drug benefit for people not enrolled in a health plan (Fee-for-Service Medicaid) visithttps://michigan.magellanrx.com. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. Information about the health care programs available through Medicaid and how to qualify. Pharmacy Benefit Administrator, BIN, PCN, Group, and telephone number Specialty Pharmacy name and telephone number Website address for pharmacy information Aetna Better Health CVS/ Caremark Phone: 1-855-364-2975 Medicare/Medicaid Members BIN: 610591 PCN: MEDDADV Group: RX8812 Medicaid Only Members BIN: 610591 PCN: ADV Group: RX8810 Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. Required if text is needed for clarification or detail. The shaded area shows the new codes. Note: The format for entering a date is different than the date format in the POS system ***. Required - If claim is for a compound prescription, list total # of units for claim. Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Providers can collect co-pay from the member at the time of service or establish other payment methods. Required if other insurance information is available for coordination of benefits. Nursing facilities must furnish IV equipment for their patients. October 3, 2022 Stakeholder Meeting Presentation. these fields were not required. All electronic claims must be submitted through a pharmacy switch vendor. 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. BIN 610591 20107 610649 4336 4336 610494 11529 PCN ADV KY 3191501 MCAIDADV MCAIDADV 4040 P022011529 GROUP RX8831 WKVA RX5035 RX8893 ACUKY KY Medicaid PBM CVS Caremark IngenioRx Humana Pharmacy Solutions CVS Caremark CVS Caremark Optum Rx Magellan Kentucky Medicaid Bin/PCN/Group Numbers Effective 1/1/2021. Required for partial fills. It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. Birth, Death, Marriage and Divorce Records. All Medicaid members are assigned a CIN even if they are enrolled in a Medicaid managed care (MMC) plan. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. ORDHSFFS : Advanced Health 800-788-2949 003585 38900 AllCare ; 800-788-2949 ; 003585 : BNR=Brand Name Required), claim will pay with DAW9. The resubmitted request must be completed in the same manner as an original reconsideration request. Medicare-Medicaid Coordination Private Insurance Innovation Center Regulations & Guidance Research, Statistics, Data & Systems Outreach & Education Back to HPMS Guidance History Clarification of Unique BIN (or BIN/PCN) Requirements as of January 1, 2012 Title Clarification of Unique BIN (or BIN/PCN) Requirements as of January 1, 2012 Date Indicates that the drug was purchased through the 340B Drug Pricing Program. Medi-Cal Rx Customer Service Center 1-800-977-2273. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. Contact the plan provider for additional information. The MC plans will share with the Department the PAs that have been previously approved. Is the CSHCN Services Program a subdivision of Medicaid? Applicable co-pay is automatically deducted from the provider's payment during claims processing. Author: jessica.jump Created Date: Services cannot be withheld if the member is unable to pay the co-pay. Use BIN Number 61499 for all claims except ADAP claims. Comments will be solicited once per calendar quarter. MediCalRx. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. Those who disenroll Required if Patient Pay Amount (505-F5) includes deductible. PAs for drugs previously authorized by MC plans will be recognized/honored by the FFS program following the Carve-Out. below list the mandatory data fields. The PCN has two formats, which are comprised of 10 characters: ", 00 = If claim is a multi-ingredient compound transaction, Required - If claim is for a compound prescription, enter "00.". No products in the category are Medical Assistance Program benefits. Submit Prior Authorization requests to Medi-Cal Rx by: Fax to 800-869-4325. Prescription cough and cold products may be approved with prior authorization for an acute condition for Dual Eligible (Medicare-Medicaid) members. Information on Adult Protective Services, Independent Living Services, Adult Community Placement Services, and HIV/AIDS Support Services. Required if a repeating field is in error, to identify repeating field occurrence. Instructions for checking enrollment status, and enrollment tips can be found in this article. Information about audits conducted by the Office of Audit. Effective April 1, 2021, Medicaid members enrolled in mainstream Managed Care (MC) plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plan (SNPs) will receive their pharmacy benefits through the Medicaid FFS Pharmacy Program instead of through their Medicaid MC plan as they do now. Information on How to Bid, Requests for Proposals, forms and publications, contractor rates, and manuals. 05 = Amount of Co-pay (518-FI) The plan deposits Drugs administered in the hospital are part of the hospital fee. A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. Q. A federal program which helps persons admitted into the U.S. as refugees to become self-sufficient after their arrival. Sent when DUR intervention is encountered during claim adjudication. PARs are reviewed by the Department or the pharmacy benefit manager. Commissioner 06 = Patient Pay Amount (505-F5) For more information contact the plan. 12 -A2 VERSION/RELEASE NUMBER D M 13 -A3 TRANSACTION CODE B1 M 14 -A4 PROCESSOR CONTROL NUMBER Enter "WIPARTD" for SeniorCare , Wisconsin Chronic Disease Program (WCDP ), and AIDS/HIV Drug Assistance Program (ADAP) member s The offer to counsel shall be face-to-face communication whenever practical or by telephone. All products in this category are regular Medical Assistance Program benefits. 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. Any other pharmacy-related questions can be directed to the Medicaid Pharmacy Program at 1-800-437-9101. PCN:ADV Group: RX8834 AmeriHealth Caritas General Provider Issues - Call PerformRx Provider Relations - 1-800-684-5502 Pharmacy Contracting Issues - Call PerformRx - 1-800-555-5690 AmeriHealth Caritas Member with Issues - Have the Member Call Perform Rx Member Services - 1-866-452-1040 Claims/Billing Issues - Call PerformRx - 1-800-684-5502 The Michigan Medicaid Health Plan Common Formulary can be found at Michigan.gov/MCOpharmacy. The benefit information provided is a brief summary, not a complete description of benefits. Information on DHS Applications and Forms grouped by category. M - Mandatory as defined by NCPDP R - Required as defined by the Processor RW -Situational as defined by Plan. Pharmacies should retrieve their Remittance Advice (RA) or X12N 835 through the Provider Web Portal. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. The Medicaid Update is a monthly publication of the New York State Department of Health. information about the Department's public safety programs. If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. For the expanded income group, if the prescriber confirms that the drug was not prescribed in relation to a family planning visit, then it will be denied. Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition. In addition, some products are excluded from coverage and are listed in the Restricted Products section. All written prescriptions for Medicaid fee-for-service recipients are required to have at least one of the industry-recognized security features from each of the three categories of characteristics: If a pharmacist is presented with a prescription that does not meet the tamper-resistant prescription pad requirements and elects to call the prescriber to verify the prescription by telephone, the pharmacist must document the following information on the prescription: Effective Nov. 3, 2022, NC Medicaid Pharmacy Fee Schedules are located in the Fee Schedule and Covered Code site. Transitioning the pharmacy benefit from MC to FFS will provide the State with full visibility into prescription drug costs, allow centralization of the benefit, leverage negotiation power, and provide a single drug formulary with standardized utilization management protocols simplifying and streamlining the drug benefit for Medicaid members. Members in the STAR program can get Medicaid benefits like: Regular checkups with the doctor and dentist. Required when needed to communicate DUR information. Required if Approved Message Code (548-6F) is used. Information & resources for Community and Faith-Based partners. Required if this field could result in contractually agreed upon payment. The Michigan Domestic & Sexual Violence Prevention and Treatment Board administers state and federal funding for domestic violence shelters and advocacy services, develops and recommends policy, and develops and provides technical assistance and training. Paper claims may be submitted using a pharmacy claim form. Each PA may be extended one time for 90 days. Substitution Allowed - Pharmacist Selected Product Dispensed, 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. Pursuant to 42CFR 455.10(b) and 42CFR 455.440, Health First Colorado will not pay for prescriptions written by unenrolled prescribers. "P" indicates the quantity dispensed is a partial fill. Required if needed to supply additional information for the utilization conflict. Andrew M. Cuomo Medicare evaluates plans based on a 5-Star rating system. Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. In certain situations, you can. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. 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). The PCN has two formats, which are comprised of 10 characters: First format for 3-digit Electronic Transaction Identification Number (ETIN): "Y" - (Yes, read Certification statement) - (1) Pharmacists Initials- (2) Provider PIN Number- (4) Drug used for erectile or sexual dysfunction. Instructions for checking enrollment status, and enrollment tips can be found in this article. Required if necessary as component of Gross Amount Due. Members in these eligibility categories are also eligible to receive family planning-related services at a $0 co-pay (please see the Family Planning Related Pharmacy Billing below for more information). gcse.src = (document.location.protocol == 'https:' ? The Pharmacy Carve-Out does not apply to members enrolled in Managed Long-Term Care plans (e.g., MLTC, PACE and MAP), the Essential Plan, or Child Health Plus (CHP). DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication. Information on adoption programs, adoption resources, locating birth parents and obtaining information from adoption records. The following MA Bulletins apply to 340B covered entities that bill the MA FFS program for 340B purchased drugs: MAB 99-17-09: Payment for Covered Outpatient Drugs MAB 24-18-21: Professional Dispensing Fee 2023 Pennsylvania Medical Assistance BIN/PCN/Group Numbers Last Updated December 22, 2022 Required if needed to provide a support telephone number of the other payer to the receiver. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), BPG Lookup UNMASK and CONNECT hidden payer information across data vendors Leverage PRECISIONxtract's dedicated team of payer data experts, our curated relationships to Payers and PBMs, and the BPG Lookup product to map the BIN PCN GROUP identifiers in your dataset to a Health Plan. The State Fiscal Year (SFY) 2021-22 enacted budget delays the transition of the Medicaid Pharmacy benefit to the Medicaid Fee-for-Service (FFS) Pharmacy Program by two years, until April 1, 2023. Prescribers are encouraged to write prescriptions for preferred products. Required for partial fills. You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. State of New York, Howard A. Zucker, M.D., J.D. PCN Phone Fax Email HPMMCD (Medicaid) 866-984-6462 877-355-8070 info@meridianrx.com . Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). Field # NCPDP Field Name Value Req Comment 11-A1 BIN Number 004336, 610591 610084, 021007 020107, 020396 025052 M Office of Health Insurance Programs, New York State Medicaid Update - December Pharmacy Carve Out: Part One Special Edition 2020 Volume 36 - Number 17, Health & Safety in the Home, Workplace & Outdoors, Clinical Guidelines, Standards & Quality of Care, All Health Care Professionals & Patient Safety, December 2020 DOH Medicaid Updates - Volume 36, Information for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Providers, Medicaid Pharmacy List of Reimbursable Drugs, Durable Medical Equipment, Prosthetics and Supplies Manual, Transition and Communications Activities Timeline document, Attention: Pharmacies Durable Medical Equipment, Prosthetics, Orthotics, and Supply Providers, and Prescribers That are Not Enrolled in Medicaid Fee-for-Service, NYS Pharmacy Benefit Information Center website, Pharmacy Carve-Out and Frequently Asked Questions (FAQs), Supplies Covered Under the Pharmacy Benefit, Medicaid Preferred Diabetic Supply Program, NYS Medicaid Program Pharmacists As Immunizers Fact Sheet, James V. McDonald, M.D., M.P.H., Acting Commissioner, Multisystem Inflammatory Syndrome in Children (MIS-C), Addressing the Opioid Epidemic in New York State, Health Care and Mental Hygiene Worker Bonus Program, Maternal Mortality & Disparate Racial Outcomes, Help Increasing the Text Size in Your Web Browser, Covered outpatient prescription and over-the-counter (OTC) drugs that are listed on the, Pharmacist administered vaccines and supplies listed in the. Not Pay for prescriptions written by unenrolled prescribers co-pay ( 518-FI ) the plan forms grouped category... Required - if claim is for a compound prescription, list total # of units for claim ensure that approved! Ask for reconsideration ( below ) you must be submitted using a claim! To become self-sufficient after their arrival criteria is attached to the Medicaid pharmacy Program at 1-800-437-9101 any other pharmacy-related can. Will Pay with DAW9 those who disenroll required if other insurance information is for. 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