Required for partial fills. PB 18-08 340B Claim Submission Requirements and We anticipate that our pricing file updates will be completed no later than February 1, 2021. Date of service for the Associated Prescription/Service Reference Number (456-EN). The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. If the reconsideration is denied, the final option is to appeal the reconsideration. This dollar amount will be provided, when known, to the receiver when the transaction had spending account dollars reported as part of the patient pay amount. 13 = Amount Attributed to Processor Fee (571-NZ). WebIn a physical inventory model, a prescription for an Eligible Patient could be filled partially with drugs from the Section 340B inventory and partially with drugs from the non-Section 340B inventory for such reasons as inventory shortage, short All necessary forms should be submitted to Magellan Rx Management at: There are four exceptions to the 120-day rule: Each of these exceptions is detailed below along with the specific instructions for submitting claims. 340B Information Exchange Reference Guide - NCPDP AMOUNT ATTRIBUTED TO PRODUCT SELECTION/BRAND DRUG. 522-fm basis of reimbursement determination r 523-fn amount attributed to sales tax r 512-fc accumulated deductible amount r 513-fd remaining deductible amount r 514-fe remaining benefit amount r 517-fh amount applied to periodic deductible r 518-fi amount of copay r 52-fk amount exceeding periodic 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) Required when needed to identify the actual cardholder or employer group, to identify appropriate group number when available. 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. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). United States Health Information Knowledgebase Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). ", 00 = If claim is a multi-ingredient compound transaction, Required - If claim is for a compound prescription, enter "00.". Note: Colorados Pharmacy Benefit Manager, Magellan, will force a $0 cost in the end. Q,iDfh|)vCDD&I}nd~S&":@*DcS|]!ph);`s/EyxS5] zVHJ~4]T}+1d'R(3sk0YwIz$[))xB:H U]yno- VN1!Q`d/%a^4\+ feCDX$t]Sd?QT"I/%. Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. Required when additional text is needed for clarification or detail. %PDF-1.5 % 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. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. These values are for covered outpatient drugs. Delayed notification to the pharmacy of eligibility. Caremark 1727 0 obj <>/Encrypt 1711 0 R/Filter/FlateDecode/ID[]/Index[1710 41]/Info 1709 0 R/Length 94/Prev 551050/Root 1712 0 R/Size 1751/Type/XRef/W[1 3 1]>>stream Required when Basis of Cost Determination (432-DN) is submitted on billing.