The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. Your session is about to timeout due to inactivity. 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. Required if this field is reporting a contractually agreed upon payment. The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. Mental illness as defined in C.R.S 10-16-104 (5.5). Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Does not obligate you to see Health First Colorado members. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. 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.) 1-5 = Refill number - Number of the replenishment, 8 = Substitution Allowed-Generic Drug Not Available in Marketplace, 1-99 = Authorized Refill number - with 99 being as needed, refills unlimited, 8 = Process Compound For Approved Ingredients. Enrolled Medicaid fee-for-service (FFS) members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies. Appeals to the Office of Administrative Courts must be filed in writing within 60 days from the mailing date of the reconsideration denial. If the reconsideration is denied, the final option is to appeal the reconsideration. For all other information as it relates to family planning benefits, please visit the Maternal, Child and Reproductive Health billing manual web page. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. Restricted products by participating companies are covered as follows: The following are not benefits of the Health First Colorado program: The following are not pharmacy benefits of the Health First Colorado program: The pharmacy benefit manager provides a Pharmacy Support Center to handle clinical, technical, and member calls. Required if needed to match the reversal to the original billing transaction. Copies of all forms necessary for submitting claims are also available on the Pharmacy Resources web page of the Department's website. This value is the prescription number from the first partial fill. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Required when there is payment from another source. 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. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. Additionally, all providers entering 340B claims must be registered and active with HRSA. Drugs administered in clinics, these must be billed by the clinic on a professional claim. 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. For DAW 8-generic not available in marketplace or DAW 9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Patient Requested Product Dispensed. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. Effective 10/22/2021, Corrected formatting error; replaced "" with numeric "0", Proposed rendering provider (if identified on the PAR), Non-preferred agents subject to the Preferred Drug List (PDL), Preferred agents with clinical criteria attached to the medication and all non-preferred agents subject to the Preferred Drug List (PDL) Over-the-counter (OTC) drugs that are not a regular Health First Colorado program benefit, Intravenous (IV) solutions with clinical criteria attached to the medication, Total Parenteral Nutrition (TPN) therapy and drugs, Significance of impact on the health of the Health First Colorado program population, Required monitoring of prescribing protocols to protect both the long-term efficacy of the drug and the public health, Potential for, or a history of, drug diversion and other illegal utilization, Appearance of the Health First Colorado program usage in amounts inconsistent with non- medical assistance program usage patterns, after adjusting for population characteristics, Clinical safety and efficacy compared to other drugs in that class of medications, Availability of more cost-effective comparable alternatives, Procedures where inappropriate utilization has been reported in medical literature, Performing auditing services with constant review on drug utilization. Appeals may be sent to: With few exceptions, providers are required to submit claims electronically. "Required when." Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. 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)). Drugs administered in a dialysis unit are part of the dialysis fee or billed on a professional claim. Required if Previous Date Of Fill (530-FU) is used. Date of service for the Associated Prescription/Service Reference Number (456-EN). 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. 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). 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. Required if necessary as component of Gross Amount Due. All claims for incremental and subsequent fills require valid values in the following fields: Please note: if a pharmacy submits a claim for a non-Schedule II medication and includes a value for quantity prescribed, it must be a valid value. Providers must submit accurate information. 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. Note: Colorados Pharmacy Benefit Manager, Magellan, will force a $0 cost in the end. Required if needed to supply additional information for the utilization conflict. Members within this eligibility category will not be subject to utilization management policies as outlined in the Appendix P, Preferred Drug List (PDL) or Appendix Y. If a member requires a refill before 50% of the day supply has lapsed, please provide the Pharmacy Support Center details of the extenuating circumstances. Member's 7-character Medical Assistance Program ID. 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. "P" indicates the quantity dispensed is a partial fill. Interactive claim submission must comply with Colorado D.0 Requirements. Applicable co-pay is automatically deducted from the provider's payment during claims processing. Electronic claim submissions must meet timely filing requirements. Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. 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. Required if needed to provide a support telephone number of the other payer to the receiver. Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. 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SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). Product may require PAR based on brand-name coverage. 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. Required if utilization conflict is detected. Realspace Hs-Mg-2072 Espresso Magellan Manager Desk, 58-3/4 x 23-1/4 x 30". Updated Lost/Stolen/Damaged/Vacation Prescriptions section - police report is no longer required for Stolen Medications, PAR Process: Updated notification letter section, Partial Fills and/or Prescription: Updated partial fill criteria, Updated contact information on page 15, to include Magellan's helpdesk info. 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. 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. Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. Please remove them. Print & Catalog Icons, Realspace Hs-Mg-2072 Espresso Magellan Collection Manager Desk. 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. No blanks allowed. 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. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. 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. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). All services to women in the maternity cycle. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). All electronic claims must be submitted through a pharmacy switch vendor. Values other than 0, 1, 08 and 09 will deny. 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. Nursing facilities must furnish IV equipment for their patients. Medication Requiring PAR - Update to Over-the-counter products. If PAR is authorized, claim will pay with DAW1. Required if Other Amount Claimed Submitted (480-H9) is greater than zero (0). If the original fills for these claims have no authorized refills a new RX number is required. 01 = Amount Applied to Periodic Deductible (517-FH), 06 = Patient Pay Applied to Amount (only if Periodic Prior Payer was still Deductible in NCPDP version, MA = Medication Administration - use for vaccine. Required if needed to identify the transaction. Updated Partial Fill Section to read Incremental Fills and/or Prescription Splitting, Updated Quantity Prescribed valid value policy, Updated the diagnosis codes in COVID-19 zero copay section. These source documents, in addition to any work papers and records used to create electronic media claims, shall be retained by the provider for six years and shall be made readily available and produced upon request of the Secretary of the Department of Health and Human Services, the Department, and the Medicaid Fraud Control Unit and their authorized agents.
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