Members who were formerly in foster care are co-pay exempt until their 26th birthday, Services provided by Community Mental Health Services, Members receiving a prescription for Tobacco Cessation Product. Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. A 7.5 percent tolerance is allowed between fills for Synagis. Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. Current beneficiaries can find out which health plan theyareenrolled in bycalling the Beneficiary Help Line at 800-642-3195 (TTY 866-501-5656) or bylogging in to theirmyHealth Portal account online atwww.michigan.gov/myhealthportal. Medicaid pharmacy policy and operations questions should be directed to (518)4863209. 014203 . Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately. Note: The format for entering a date is different than the date format in the POS system ***. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT, Required for all COB claims with Other Coverage Code of 2 or 4. 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with a Covered Outpatient Drug (COD) status equal to DESI - 5 (LTE/IRS drug for all indications or DESI 6 LTE/IRS drug withdrawn from market)]. M -Mandatory as defined by NCPDP R -Required as defined by the Processor RW -Situational as defined by Plan Transaction Header Segment: Mandatory Field # NCPDP Field Name Value Req Comment 11-A1 BIN Number 004336, 610591 012114, 013089 020396 . Behavioral and Physical Health and Aging Services Administration, Immunization Info for Families & Providers, Michigan Maternal Mortality Surveillance Program, Informed Consent for Abortion for Patients, Informed Consent for Abortion for Providers, Go to Child Welfare Medical and Behavioral Health Resources, Go to Children's Special Health Care Services, General Information For Families About CSHCS, Go to Emergency Relief: Home, Utilities & Burial, Supplemental Nutrition Assistance Program Education, Go to Low-income Households Water Assistance Program (LIHWAP), Go to Children's & Adult Protective Services, Go to Children's Trust Fund - Abuse Prevention, Bureau of Emergency Preparedness, EMS, and Systems of Care, Division of Emergency Preparedness & Response, Infant Safe Sleep for EMS Agencies and Fire Departments, Go to Adult Behavioral Health & Developmental Disability, Behavioral Health Information Sharing & Privacy, Integrated Treatment for Co-occurring Disorders, Cardiovascular Health, Nutrition & Physical Activity, Office of Equity and Minority Health (OEMH), Communicable Disease Information and Resources, Mother Infant Health & Equity Improvement Plan (MIHEIP), Michigan Perinatal Quality Collaborative (MI PQC), Mother Infant Health & Equity Collaborative (MIHEC) Meetings, Go to Birth, Death, Marriage and Divorce Records, Child Lead Exposure Elimination Commission, Coronavirus Task Force on Racial Disparities, Michigan Commission on Services to the Aging, Nursing Home Workforce Stabilization Council, Guy Thompson Parent Advisory Council (GTPAC), Strengthening Our Focus on Children & Families, Supports for Working with Youth Who Identify as LGBTQ, Go to Contractor and Subrecipient Resources, Civil Monetary Penalty (CMP) Grant Program, Nurse Aide Training and Testing Reimbursement Forms and Instructions, MI Kids Now Student Loan Repayment Program, Michigan Opioid Treatment Access Loan Repayment Program, MI Interagency Migrant Services Committee, Go to Protect MiFamily -Title IV-E Waiver, Students in Energy Efficiency-Related Field, Go to Community & Volunteer Opportunities, Go to Reports & Statistics - Health Services, Other Chronic Disease & Injury Control Data, Nondiscrimination Statement (No discriminacion), 2022-2024 Social Determinants of Health Strategy, Go to Reports & Statistics - Human Services, Post-Single PDL Changes (after October 1, 2020), Medicaid Health Plan BIN, PCN and Group Information, Drug Class & Workgroup Review Schedule for 2023. Required if Help Desk Phone Number (550-8F) is used. Sent when claim adjudication outcome requires subsequent PA number for payment. Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. Members of these eligibility categories will be subject to utilization management policies as outlined in the Appendix P, PDL or Appendix Y. Adult Behavioral Health & Developmental Disability Services. Copies of all forms necessary for submitting claims are also available on the Pharmacy Resources web page of the Department's website. Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The next drug classes to be reviewed by the Workgroup include Anti-Infective, Contraceptives, MCO Miscellaneous and Asthma/Allergy/COPD. SCO Plan- Medicaid Only PBM BIN PCN Group Pharmacy Help Desk Commonwealth Care Alliance Navitus 610602 MCD MHO (877) 908-6023 Senior Whole Health CVS 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. Vision and hearing care. 01 = Amount applied to periodic deductible (517-FH) All member ID numbers will be the same for the beneficiary whether they are enrolled in a health plan or in NC Medicaid Direct. Prescribers may continue to write prescriptions for drugs not on the PDL. Required - If claim is for a compound prescription, enter "0. 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. })(); Chart of 2022 BIN and PCN values for each Medicare Part D prescription drug plan Part 4 of 6 (H5337 through H7322). M - Mandatory as defined by NCPDP R - Required as defined by the Processor RW -Situational as defined by Plan. Payer Name: Iowa Medicaid Enterprise Date: August 14, 22 Plan Name/Group Name: Iowa Medicaid BIN:11933 PCN:IAPOP Processor: IME POS Unit (CHC) Effective as of September 21, 22 NCPDP Telecommunication Standard Version/Release #: D. NCPDP Data Dictionary Version Date: July 27 NCPDP External Code List Version Date: April 218 Member's 7-character Medical Assistance Program ID. All Medicaid members are assigned a CIN even if they are enrolled in a Medicaid managed care (MMC) plan. Resources and information to assist in assuring firearm safety for families in the state of Michigan. 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. Added Temporary COVID section, updated Provider Web Portal link, Updated verbiage to include the NCPDP D.0 guidelines for field 460-ET, Updated DAW Codes: Updated Dispense as Written (DAW) Override Code table. Timely filing for electronic and paper claim submission is 120 days from the date of service. Scroll down for health plan specific information. Required if utilization conflict is detected. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. A letter was mailed to each member with more information. Supplies listed in the Pharmacy Procedures and Supply Codes, such as enteral and parenteral nutrition, family planning and medical/surgical supplies are subject to the Pharmacy Carve-Out. The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. To learn more, view our full privacy policy. 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. Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. Effective April 1, 2021, the following Medicaid Pharmacy FFS Programs will also apply to Medicaid managed care members: Please refer to the October 2020 Medicaid Update article titled Attention: Pharmacies Durable Medical Equipment, Prosthetics, Orthotics, and Supply Providers, and Prescribers That are Not Enrolled in Medicaid Fee-for-Service. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. The Michigan Department of Health and Human Services' (MDHHS) Division of Environmental Health (DEH) uses the best available science to reduce, eliminate, or prevent harm from environmental, chemical, and physical hazards. Information on the Family Independence Program, State Disability Assistance, SSI, Refugee, and other cash assistance. Prescription drugs and vaccines. Plan PBM Phone BIN PCN Group OHA (Fee-for-Service or "Open Card") 888-202-2126 . The new BIN and PCN are listed below. A federal program which helps persons admitted into the U.S. as refugees to become self-sufficient after their arrival. TheNC Medicaid Preferred Drug List (PDL)allows NC Medicaid to obtain better prices for covered outpatient drugs through supplemental rebates. 03 =Amount Attributed to Sales Tax (523-FN) 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. 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. The situations designated have qualifications for usage ("Required if x", "Not required if y"). DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. The PCN (Processor Control Number) is required to be submitted in field 104-A4. 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) The form is one-sided and requires an authorized signature. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. information about the Department's public safety programs. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Required if Other Amount Claimed Submitted (480-H9) is greater than zero (0). Prescription Exception Requests. "Required when." Sent when Other Health Insurance (OHI) is encountered during claim processing. 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. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. Please call a Health Program Representative (HPR) at 1-866-608-9422 with Medicaid benefit questions. Date of service for the Associated Prescription/Service Reference Number (456-EN). Group: ACULA. Plan Name/Group Name: Illinois Medicaid BIN: 1784 PCN: ILPOP Processor: Change Healthcare (CHC) Effective as of: September 21, 22 NCPDP Telecommunication Standard Version/Release #: D. NCPDP Data Dictionary Version Date: July 27 NCPDP External Code List Version Date: July 213 Contact/Information Source: 1-877-782-5565 Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Required if needed to provide a support telephone number to the receiver. 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 Please contact individual health plans to verify their most current BIN, PCN and Group Information. the blank PCN has more than 50 records. Information on How to Bid, Requests for Proposals, forms and publications, contractor rates, and manuals. The "Dispense as Written (DAW) Override Codes" table describes the valid scenarios allowable per DAW code. New PAs and existing PA approvals that are less than 12 months are not eligible for deferment. COVID-19 early refill overrides are not available for mail-order pharmacies. Values other than 0, 1, 08 and 09 will deny. Does not obligate you to see Health First Colorado members. MassHealth PBM BIN PCN Group Primary Care Clinician (PCC) Plan Prescribers are encouraged to write prescriptions for preferred products. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. 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. The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website. Colorado Pharmacy supports up to 25 ingredients. Provider Synergies, LLC is an affiliate of Magellan Medicaid Administration contracted with AHCCCS to facilitate and collect rebates for the supplemental rebate program. No PA will be required when FFS PA requirements (e.g. OptumRx Part-D and MAPD Plans BIN: 610097 PCN: 9999 Part-D WRAP Plans BIN: 610097 PCN: 8888 PCN: 8500 OptumRx (This represents former informedRx) BIN: 610593 PCN: HNEMEDD PHPMEDD PCN: SXCFLH . 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). If a member calls the call center, the member will be directed to have the pharmacy call for the override. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER, ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Enrolling in Health First Colorado as an OPR provider: 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. Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. not used) for this payer are excluded from the template. This page provides important information related to Part D program for Pharmaceutical companies. Required for partial fills. Pharmacies should continue to rebill until a final resolution has been reached. 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). Your pharmacy coverage is included in your medical coverage. Medicare has neither reviewed nor endorsed the information on our site. Members previously enrolled in PCN were automatically enrolled in Medicaid. 05 = Amount of Co-pay (518-FI) If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. 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). 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) 10 = Amount Attributed to Provider Network Selection (133-UJ) Required if this field is reporting a contractually agreed upon payment. Pharmacies should retrieve their Remittance Advice (RA) or X12N 835 through the Provider Web Portal. Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc. It contains general information regarding the New York State's (NYS) transition strategy and other important facts that will assist providers in transitioning members to the FFS Pharmacy Program. There is no registry of PCNs. Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. Drug list criteria designates the brand product as preferred, (i.e. 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. Required on all COB claims with Other Coverage Code of 3. PBM Processor BIN Number PCN Rx Group Number AmeriHealth Caritas PerformRx 019595 PRX00801 N/A Carolina Complete Health Envolve Rx (back end CVS Health) 004336 MCAIDADV RX5480 Healthy Blue . correct diagnosis) are met, according to the member's managed care claims history. Is the CSHCN Services Program a subdivision of Medicaid? 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) Required for partial fills. Hospital care and services. 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. 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. Pharmacies should direct any questions about claims for beneficiaries enrolled in a managed care health plan to that members health plan. Click here to let us know, Learn more about savings on Pet Medications, 007, 008, 011, 013, 015, 016, 017, 808, 810, 001, 004-010, 019, 020, 028, 030, 033, 034, 040, 045, 052-055, 064-090, 001, 003-006, 010, 011, 019, 021, 022, 024, 026, 029-036, 038, Highmark Blue Cross Blue Shield of Western New York and Highmark Blue Shield of Northeastern New York, Community Health Plan of WA Medicare Advantage, 007, 008, 009, 010, 011, 012, 013, 014, 015, 808, 810, Senior LIFE Altoona / Ebensburg / Indiana, CareFirst BlueCross BlueShield Medicare Advantage, Blue Cross and Blue Shield of Louisiana HMO. 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. 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). Those who disenroll Medication Requiring PAR - Update to Over-the-counter products. 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. Required if Incentive Amount Submitted (438-E3) is greater than zero (0). Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. 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. Providers may submit coverage exception requests by fax, phone or electronically: For BCCHP plans, fax 877-480-8130, call 1-866-202-3474 (TTY/TDD 711) or submit electronically on MyPrime or CoverMyMeds login page. 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. If the medication has been determined to be family planning or family planning-related, it should be documented in the prescription record. Information on DHS Applications and Forms grouped by category. Bridge Card Participation Information on Electronic Benefits for clients and businesses, lists of participating retailers and ATMs, and QUEST. The Processor Control Numbers (PCN) (Field 14A4) will change to: o "DRTXPROD" for Medicaid, CHIP, and CSHCN claims. Required if Other Payer patient Responsibility Amount (352-NQ) is submitted. Children's Special Health Care Services information and FAQ's. Medicare evaluates plans based on a 5-Star rating system. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. 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. Benefits under STAR. Information on the Safe Delivery Program, laws, and publications. Member Contact Center1-800-221-3943/State Relay: 711. 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. 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. Instructions for checking enrollment status, and enrollment tips can be found in this article. Centers for Medicare and Medicaid Services (CMS) - This site has a wealth of information concerning the Medicaid Program.
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