Signature requirements are temporarily waived for Member Counseling and Proof of Delivery. 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). Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. Required when a Medicare Part D payer applies financial amounts to Medicare Part D beneficiary benefit stages. PB 18-08 340B Claim Submission Requirements and 07 = Amount of Co-insurance (572-4U) 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) Required when necessary to identify the Patient's portion of the Sales Tax. 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. No blanks allowed. The maternity cycle is the time period during the pregnancy and 365days' post-partum. 19 Antivirals Dispensing and Reimbursement 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. Required when needed to communicate DUR information. Sent if reversal results in generation of pricing detail. B. 0 Required if the identification to be used in future transactions is different than what was submitted on the request. Local and out-of-state pharmacies may provide mail-order prescriptions for Medicaid members if they are enrolled with the Health First Colorado program and are registered and in good standing with the State Board of Pharmacy. Required when needed to supply additional information for the utilization conflict. ADDITIONAL MESSAGE INFORMATION CONTINUITY. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL These will be handled on a case-by-case basis by the Pharmacy Support Center if requested by a Health First Colorado healthcare professional (i.e. 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. A pharmacy should utilize field 461-EU on a pharmacy claim to indicate 6-Family Plan to receive a $0 co-pay on family planning related medications. Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Payer Issued, One transaction for B2 or compound claim, Four allowed for B1 or B3, Code qualifying the 'Service Provider ID' (Field # 201-B1), This will be provided by the provider's software vendor, Assigned when vendor is certified with Magellan Rx Management - If not number is supplied, populate with zeros, UNITED STATES AND CANADIAN PROVINCE POSTAL SERVICE. Required when other insurance information is available for coordination of benefits. Required when its value has an effect on the Gross Amount Due (430-DU) calculation. Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. Required if this field is reporting a contractually agreed upon payment. Prior Authorization Request (PAR) Process, Guidelines Used by the Department for Determining PAR Criteria, Incremental Fills and/or Prescription Splitting, Lost/Stolen/Damaged/Vacation Prescriptions, Temporary COVID-19 Policy and Billing Changes, Medication Prior Authorization Deferments, EUA COVID-19 Antivirals Claim Requirements, Ordering, Prescribing or Referring (OPR) Providers, Delayed Notification to the Pharmacy of Eligibility, Instructions for Completing the Pharmacy Claim Form, Response Claim Billing/Claim Rebill Payer Sheet Template, Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response, Claim Billing/Claim Rebill PAID (or Duplicate of PAID) Response, Claim Billing/Claim Rebill Accepted/Rejected Response, Claim Billing/Claim Rebill Rejected/Rejected Response, NCPDP Version D.0 Claim Reversal Template, Request Claim Reversal Payer Sheet Template, Response Claim Reversal Payer Sheet Template, Claim Reversal Accepted/Approved Response, Claim Reversal Accepted/Rejected Response, Claim Reversal Rejected/Rejected Response, Pharmacy Prior Authorization Policies section. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Pharmacies may call the Pharmacy Support Center to request a quantity limit override 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. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. All electronic claims must be submitted through a pharmacy switch vendor. The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Required when needed per trading partner agreement. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. Durable Medical Equipment (DME), these must be billed as a medical benefit on a professional claim. The following lists the segments and fields in a Claim Billing or Claim Rebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0.

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