Pharmacy Billing Manual

Pharmacy Requirements and Benefits

This pharmacy billing manual explains many of the Colorado Department of Health Care Policy & Financing's (the Department) policies regarding billing, provider responsibilities, and program benefits. Providers should also consult the Code of Colorado Regulations (10 C.C.R. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements.

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1990 OBRA Rebate Program

Federal regulation requires that drug manufacturers sign a national rebate agreement with the Centers for Medicare and Medicaid Services (CMS) to participate in the state Medical Assistance Program. 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. In addition, some products are excluded from coverage and are listed in the Restricted Products section. 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.

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Prior Authorization Request (PAR) Process

Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program.

The procedure to request a PAR and the medications that require a PAR are outlined in Appendix P – Prior Authorization Procedures and Criteria located in the Pharmacy Prior Authorization Policies section of the Department's website.

PARs are reviewed by the Department or the pharmacy benefit manager. All pharmacy PARs must be telephoned or faxed by the prescribing physician or physician's agent to the Pharmacy Benefit Manager Support Center. Notification of PAR approval or denial is sent to each of the following parties:

  • Requesting physician
  • Proposed rendering provider (if identified on the PAR)
  • Member

In addition to stating whether the PAR has been approved or denied, a PAR denial notification letter is sent to members. This letter identifies the member's appeal rights. Only members have the right to appeal a PAR decision.

 

If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax.

Approval of a PAR does not guarantee payment. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. Some claim submission requirements include timely filing, eligibility requirements, pursuit of third-party resources, and required attachments included. A PAR approval does not override any of the claim submission requirements.

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Medications Requiring a PAR

  • Certain restricted drugs
  • 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

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Guidelines Used by the Department for Determining PAR Criteria

In determining what drugs should be subject to prior authorization, the following criteria is used:

  • 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

 

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Generic Mandate

Most brand-name drugs with a generic therapeutic equivalent are not covered by the Health First Colorado program.

Members can receive a brand name drug without a PAR if:

  • Only a brand name drug is manufactured.
  • A generic drug is not therapeutically equivalent to the brand name drug.
  • The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication.
  • The drug is for the treatment of:
    • Mental illness as defined in C.R.S 10-16-104 (5.5);
    • Treatment of cancer;
    • Treatment of epilepsy; or
    • Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS).

Members may receive a brand name drug with a PAR if:

  • A member has tried the generic equivalent but is unable to continue treatment on the generic drug and criteria is met for medication.
  • The physician is of an opinion that a transition to the generic equivalent of a brand-name drug would be unacceptably disruptive to the patient's stabilized drug regimen and criteria is met for medication.

The pharmacy Prior Authorization Form is available on the Pharmacy Resources web page of the Department's website.

 

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Dispensing Requirements

Refill Too Soon Policy

For DEA Schedule 2 through 5 drugs, 85 percent of the days' supply of the last fill must lapse before a drug can be filled again. For non-scheduled drugs, 75 percent of the days' supply of the last fill must lapse before a drug can be filled again. A 7.5 percent tolerance is allowed between fills for Synagis. If the appropriate numbers of days have not lapsed, the claim will be denied as a refill-too-soon unless there has been a change in the dosing. For non-mail order transactions, there is a maximum 20-day accumulation allowed every rolling 180 days. 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. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center.

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Tamper Resistant Prescription Pads

All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. This requirement stems from the Social Security Act, 42 U.S.C. 1396b (i) (23), which lists three different characteristics to be integrated into the manufacture of prescription pads. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website.

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Compounded Prescriptions

A compounded prescription (a prescription where two or more ingredients are combined to achieve a desired therapeutic effect) must be submitted on the same claim. A PAR is only necessary if an ingredient in the compound is subject to prior authorization. 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. The Health First Colorado program does not pay a compounding fee.

SNO-MED is a required field for compounds—the route of administration is required–NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2).

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Incremental Fills and/or Prescription Splitting

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.

Exception for DEA Schedule II medications: Initial Incremental fills are allowed for DEA Schedule II prescription drugs dispensed to ALL members. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements.  

Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. Incremental and subsequent fills may not be transferred from one pharmacy to another. The standard drug ingredient reimbursement methodology applies to the quantity dispensed with each fill. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date.

All claims for incremental and subsequent fills require valid values in the following fields:

  • 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)

Please see the payer sheet grid below for more detailed requirements regarding each field.

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Emergency Three-Day Supply

In an emergency, when a PAR cannot be obtained in time to fill the prescription, pharmacies may dispense a 72-hour supply (3 days) of covered outpatient prescription drugs to an eligible member by calling the Pharmacy Support Center. An emergency is any condition that is life threatening or requires immediate medical intervention.

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Lost/Stolen/Damaged/Vacation Prescriptions

The Department does not pay for early refills when needed for a vacation supply.

The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. Pharmacies must call for overrides for lost, stolen, or damaged prescriptions. If a member calls the call center, the member will be directed to have the pharmacy call for the override. Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication.

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Counseling

A pharmacist or pharmacist designee shall offer counseling regarding the drug therapy to each Health First Colorado member with a new or refill prescription if the pharmacist or pharmacist designee believes that it is in the best interest of the member. The offer to counsel shall be face-to-face communication whenever practical or by telephone. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided.

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Dispense As Written (DAW) Override Codes

DAW Code DAW Description Action Description
DAW 0 No Product Selection Indicated Allow NCPDP  Uu~Daw 0 Cannot Be Submitted Ms Drug W/Avail Generics~50740~Error List Daw0 Cant Be Submit Ms Drug W/Avail Gen
DAW 1 Substitution Not Allowed by Prescriber Allow Prescriber has indicated the brand name drug is medically necessary. Product may require PAR based on brand-name coverage. If PAR is authorized, claim will pay with DAW1.
Not Supported Claim with the generic product, NCPDP EC 8K—DAW Code Not Supported and return the supplemental message “Submitted DAW is supported with guidelines.  DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. For DAW 8-generic not available in marketplace or DAW  9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual”
DAW 2 Substitution Allowed – Patient Requested Product Dispensed Not Supported 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. For  8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual.“
DAW 3 Substitution Allowed – Pharmacist Selected Product Dispensed Not Supported 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. For  8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual
DAW 4 Substitution Allowed – Generic Drug Not in Stock Not Supported 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. For  8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual
DAW 5 Substitution Allowed – Brand Drug Dispensed as a Generic Not Supported 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. For  8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual
DAW 6 Override Not Supported 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. For  8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual
DAW 7 Substitution Not Allowed – Brand Drug Mandated by Law Not Supported 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. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. For  8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual
DAW 8 Substitution Allowed – Generic Drug Not Available in Marketplace Allow Billing ID = DAW8 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.
The drug list will update as often as necessary to accommodate for drug shortages. If drug is on list, claim will pay.

Not Supported

All Non Billing ID = DAW8

NCPDP EC 8K—DAW Code Not Supported and return the supplemental message “Submitted DAW is supported with guidelines.  DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. For DAW 8-generic not available in marketplace or DAW  9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual"
DAW 9 Allowed by Prescriber but Plan Requests Brand Allow Formulary Ind = BNR Drug list criteria designates the brand product as preferred, (i.e. BNR=Brand Name Required), claim will pay with DAW9.
Allow Formulary Ind = NPP May be used for cases where Health First Colorado’s drug list designates both a brand drug and its generic equivalent as non-preferred products and also designates that the non-preferred brand product is favored for coverage over the equivalent non-preferred generic.
Not Supported NCPDP EC 8K—DAW Code Not Supported and return the supplemental message “Submitted DAW is supported with guidelines.  DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. For DAW 8-generic not available in marketplace or DAW  9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual"

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Co-pay Exclusions

Applicable co-pay is automatically deducted from the provider's payment during claims processing. Providers can collect co-pay from the member at the time of service or establish other payment methods. Services cannot be withheld if the member is unable to pay the co-pay.

Cost-sharing for members must not exceed 5% of their monthly household income. Members that meet their monthly co-pay maximum, or 5% of their monthly household income, will be exempt from co-pay for the remainder of that month.

The following categories of members are exempt from co-pay:

  • Members who are age 18 and younger
  • Members residing in a nursing facility
  • All services to women in the maternity cycle. The maternity cycle is the time period during the pregnancy and sixty days' post-partum.
  • Members that were in foster care until their 26th birthday.
  • American Indian or Alaskan Native
  • Services provided by Community Mental Health Services.
  • Members receiving prescription for Tobacco Cessation Product

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Reversals

If the member does not pick up the prescription from the pharmacy within 14 calendar days, the prescription must be reversed on the 15th calendar day. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. Pharmacies that have an electronic tracking system shall review prescriptions in will-call status on a daily basis and enter a reversal of prescriptions not picked up within 10 days of billing. In no case, shall prescriptions be kept in will-call status for more than 14 days.

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Retention of Records

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. 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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340B Claims Processing

The following NCPDP fields below will be required on 340B transactions. These values are for covered outpatient drugs. Additionally, all providers entering 340B claims must be registered and active with HRSA.

NCPDP Field Name & Number Value Description
Submission Clarification Code (42Ø-DK) 2Ø = 340B Claim Required for 340B Claims. The value of '20' submitted in the Submission Clarification field (NCPDP Field # 42Ø-DK) to indicate a 340B transaction. Indicates that the drug was purchased through the 340B Drug Pricing Program.
Basis of Cost Determination (423-DN) Ø5 = Acquisition Cost
or
Ø8 = Disproportionate Share Pricing
Required for 340B Claims. 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).

Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats.

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Mail Order

Enrolled Medicaid fee-for-service (FFS) members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies.

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.

Non-maintenance products submitted by a pharmacy for mail order prescriptions will deny.

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Restricted Products

The Health First Colorado program restricts or excludes coverage for some drug categories. More information may be obtained in Appendix P in the Billing Manuals section of the Department's website.

Restricted products by participating companies are covered as follows:

None No products in the category are Medical Assistance Program benefits.
Limited Prior authorization requests for some products may be approved based on medical necessity.
All All products in this category are regular Medical Assistance Program benefits.
Category Benefits
Anorexia (weight loss) None
Weight gain Limited
Cosmetic purposes or hair growth None
Cough and cold * Limited
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)] None
Non-rebatable products None
Fertility None
Non-prescription drugs Aspirin, Insulin; others Limited
Prenatal vitamins All for females. None for males.
Other vitamins Limited
Barbiturates Limited
* Cough and cold products: Cough and cold products include combinations of narcotic and nonnarcotic cough suppressants, expectorants, and/or decongestants. Single agent antihistamines and their combination products with a decongestant are not considered to be cough and cold products and are regular Medical Assistance Program benefits.
** DESI drugs: DESI drugs are products that are declared "less than effective" by the FDA and are not a benefit of the Medical Assistance program.

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Exclusions

The following are not benefits of the Health First Colorado program:

  • 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. 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
  • Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate Program.
  • Fertility drugs
  • IV equipment (for example, Venopaks dispensed without the IV solutions). Nursing facilities must furnish IV equipment for their patients.
  • Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc.
  • Spirituous liquors of any kind
  • Drug used for erectile or sexual dysfunction

The following are not pharmacy benefits of the Health First Colorado program:

  • Drugs administered in the physician's office; these must be billed by the physician as a medical benefit on a professional claim.
  • Drugs administered in clinics; these must be billed by the clinic on a professional claim. Drugs administered in a dialysis unit are part of the dialysis fee or billed on a professional claim. Drugs administered in the hospital are part of the hospital fee.
  • Durable Medical Equipment (DME); these must be billed as a medical benefit on a professional claim.
  • Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility.

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Pharmacy Helpdesk

The pharmacy benefit manager provides a Pharmacy Support Center to handle clinical, technical, and member calls. The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. The Helpdesk is available 24 hours a day, seven days a week.

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Temporary COVID-19 Policy and Billing Changes

Refill Too Soon Policy

Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. 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. COVID-19 early refill overrides are not available for mail order pharmacies.

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Medication Prior Authorization Deferments

Health First Colorado is temporarily deferring medication prior authorization (PA) requirements for members on all medications for which there is an existing 12-month PA approval in place. Each PA may be extended one time for 90 days. 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. enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). New PAs and existing PA approvals that are less than 12 months are not eligible for deferment. Please contact the Pharmacy Support Center for a one-time PA deferment.

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Zero Co-pay

Health First Colorado is waiving co-pay amounts for medications related to COVID-19 when ICD-10 diagnosis code U07.1 is entered on the claim transmittal. Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription. Please contact the Pharmacy Support Center with questions. 

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Signature Requirements

Signature requirements are temporarily waived for Member Counseling and Proof of Delivery. Pharmacies are expected to keep records indicating when member counseling was not or could not be provided.

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Prescription Cough and Cold

Prescription cough and cold products for all ages will not require a prior authorization for Health First Colorado members. Prescription cough and cold products may be approved with a prior authorization for an acute condition for Dual Eligible (Medicare-Medicaid) members. Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. Cheratussin AC, Virtussin AC).

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Billing Information

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 pharmacy benefit manager processes both electronic and paper claims and provides claim, provider, eligibility, and PAR interfaces with the Medicaid Management Information System (MMIS). All electronic claims must be submitted through a pharmacy switch vendor. Claims that cannot be submitted through the vendor must be submitted on paper. Please refer to the specific rules and requirements regarding electronic and paper claims below.

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Timely Filing Requirements

Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. Timely filing for electronic and paper claim submission is 120 days from the date of service.

Pharmacies should retrieve their Remittance Advice (RA) or X12N 835 through the Provider Web Portal. Claims that do not result in the Health First Colorado program authorizing reimbursement for services rendered may be resubmitted. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. If the reconsideration is denied, the final option is to appeal the reconsideration.

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Rebilling Denied Claims

Pharmacies may electronically rebill denied claims when the claim submission is within 120 days of the date of service. Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. Pharmacies should continue to rebill until a final resolution has been reached. Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim.

Copies of all forms necessary for submitting claims are also available on the Pharmacy Resources web page of the Department's website. Instructions on how to complete the PCF are available in this manual. All necessary forms should be submitted to Magellan Rx Management at:

Magellan Health Service
Attention Paper Claims Processing
P.O. Box 85042
Richmond, VA 23242

There are four exceptions to the 120-day rule:

  • Delayed processing by third party payers
  • Retroactive member eligibility
  • Delayed notification to the pharmacy of eligibility
  • Extenuating circumstances

Each of these exceptions is detailed below along with the specific instructions for submitting claims.

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Ordering, Prescribing or Referring (OPR) Providers

Pursuant to 42CFR 455.10(b) and 42CFR 455.440, Health First Colorado will not pay for prescriptions written by unenrolled prescribers. Physicians and other practitioners who order, prescribe or refer items or services for Health First Colorado members, but who choose not to submit claims to Health First Colorado, are referred to as OPR providers. Enrolling in Health First Colorado as an OPR provider:

  • Does not obligate you to see Health First Colorado members;
  • 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
  • Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately.

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. Please visit the OPR section of the Department's website for more detailed information about enrollment and compliance with the Affordable Care Act.

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Reuse of Rx Numbers

The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. If the original fills for these claims have no authorized refills a new RX number is required.

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Delayed Processing by Third-Party Payers

Health First Colorado is the payer of last resort. 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.

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Retroactive Member Eligibility

If the timely filing period expires due to a delayed or back-dated member eligibility determination, the claim is considered timely if received within 120 days from the date the member was granted backdated eligibility.

Pharmacies can submit these claims electronically or by paper. Paper claims may be submitted using a pharmacy claim form.

Pharmacies may submit claims electronically by obtaining a PAR from the Pharmacy Support Center. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims.

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Delayed Notification to the Pharmacy of Eligibility

Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. 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.

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Extenuating Circumstances

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. 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. Pharmacy employee negligence, employer failure to provide sufficient, well-trained employees, or failure to properly monitor the activities of employees and agents (e.g., billing services) are not considered extenuating circumstances beyond the pharmacy provider's control. The detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below).

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Request for Reconsideration

When a pharmacy has exhausted all authorized rebilling procedures and has not been paid for a claim, the pharmacy may submit a Request for Reconsideration to the pharmacy benefit manager.

It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration.

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.

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. A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration.

An additional request for reconsideration may be submitted within 60 days of the reconsideration denial if information can be corrected or if additional supporting information is available. The resubmitted request must be completed in the same manner as an original reconsideration request.

The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website.

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Appealing Reconsideration Denials

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.

Representation by an attorney is usually required at administrative hearings. Appeals to the Office of Administrative Courts must be filed in writing within 60 days from the mailing date of the reconsideration denial. Appeals may be sent to:

Office of Administrative Courts
1525 Sherman Street – 4th Floor
Denver, CO 80203
Fax 303-866-5909

 

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Paper Claim Submission Requirements

With few exceptions, providers are required to submit claims electronically. Electronically mandated claims submitted on paper are processed, denied, and marked with the message "Electronic Filing Required."

The following claims can be submitted on paper and processed for payment:

  • Providers who consistently submit five or fewer claims per month;
  • Claims that are more than 120 days from the date of service that require special attachments; and
  • Reconsideration claims.

Providers can submit only one claim per submission on the PCF; however, compound claims can be submitted. Providers must submit accurate information. The use of inaccurate or false information can result in the reversal of claims.

The PCF should be submitted to Magellan Rx Management agent at:

Magellan Health Service
Attention Paper Claims Processing
P.O. Box 85042
Richmond, VA 23242

 

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Instructions for Completing the Pharmacy Claim Form

Below are the completion instructions for the Colorado Pharmacy Claim Form (PCF-2) for Pharmacy Providers. The form is one-sided and requires an authorized signature. Providers must follow the instructions below and may only submit one (prescription) per claim. The claim may be a multi-line compound claim. If there is more than a single payer, a D.0 electronic transaction must be submitted.

Note: The format for entering a date is different than the date format in the POS system ***.

Field Value Comment
I. Member Information
Member's Medicaid ID # Member's 7-character Medical Assistance Program ID Required
Group ID COMEDICAID Default value on claim form
Relationship Code 1 = Cardholder Default value on claim form
Member's Name Last, First, MI Required
Other Coverage Code
  • 0 = Not specified
  • 1 = No other coverage exists
  • 2 = Other coverage exists - payment collected
  • 3 = Other coverage exists - this claim not covered
  • 4 = Other coverage exists - payment not collected
  • Required when submitting a claim for member w/ other coverage
Member's DOB MM/DD/YYYY Required
II. Pharmacy Information
Service Provider ID NPI = National Provider Identifier Required
Service Provider ID Qualifier 01 = NPI-National Provider Identifier Required
III. Prescriber Information
Prescriber's Last Name Last Name of Prescriber Required
Prescriber's Phone # Prescriber's Phone # Required
Prescriber's ID Prescriber's NPI, CO State
License or DEA
Required
Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017.
Prescriber's ID Qualifier
  • Ø1 = NPI
  • 08 = State License #
  • 12 = DEA Number
Required
IV. Claim Information (Claim must be for same member as listed above)
Prescription # Prescription # Assigned by Pharmacy Required
Date Written MM/DD/YYYY Required
Date Filled MM/DD/YYYY Required
Fill #
  • 00 = Original
  • 01–99 = # of Refills Fill
Required
Prescription # Qualifier
  • 0 = Blank
  • 1 = Rx Billing
Required
Prescription Origin Code 1 = Written
  • 2 = Telephone
  • 3 = Electronic
  • 4 = Facsimile
  • 5 = Pharmacy
Required
Days Supply # of Days Prescription is Prescribed Required
DAW Codes
  • 0 = No Generic
  • 1 = Substitution Not Allowed by Prescriber
  • 8 = Substitution Allowed – Generic Drug Not Available in Marketplace
  • 9 = Substitution Allowed by Prescriber but Plan Requests Brand
Values other than Ø, 1, 08 and 09 will deny. The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code.
PA Type Code 0 = Not Specified  
Quantity Prescribed Metric Decimal Quantity Required – If claim is for a compound prescription, list total # of units for claim.
Quantity Dispensed Metric Decimal Quantity Required – If claim is for a compound prescription, list total # of units for claim.
Product ID NDC # Required – If claim is for a compound prescription, enter "0."
Product ID Qualifier 00 = If claim is a multi-ingredient compound transaction
03 = National Drug Code (NDC)
Required – If claim is for a compound prescription, enter "00."
Submitted Ingredient Cost   Required – Enter total ingredient costs even if claim is for a compound prescription.
Total Charge   Required – Pharmacy's Usual and Customary Charge
Gross Amount Due   Required
Unit of Measure   Required
V. Other Payer Information
Other Payer Cov Type 01 = Primary Required if Other Cov Code equals 2, 3, or 4
Other Payer Date MM/DD/YYYY Required if Other Cov Code equals 2, 3, or 4
Other Payer $ Paid   Required if Other Cov Code equals 2, 3, or 4
Other Payer $ Paid Qualifier
  • 02 = Shipping
  • 03 = Postage Service
  • 04 = Administrative
  • 05 = Incentive
  • 06 = Cognitive
  • 07 = Drug Benefit
  • 09 = Compound Preparation Cost
  • 10 = Sales Tax
Required if Other Cov Code equals 2, 3, or 4
Other Payer Reject Code Value from Prior Payer Required if Other Cov Code equals 3
Other Payer Patient Responsibility $ Value from Prior Payer Required if Other Cov Code equals 4
Other Payer Patient Responsibility $ Qualifier
  • 01 = Amount
  • 05 = Amount of 5.1 Co-pay
  • 07 = Amount of Coinsurance
Required if Other Cov Code equals 4
Compound Claim
  • Blank
  • 0 = Not a Claim Specified
  • 1 = Not a Compound
  • 2 = Claim is a Compound Claim
Required when claim is for a compound prescription
Diagnosis Code Qualifier 02 = ICD10 Code  
Diagnosis Code ICD10  
RX Override 8 = Process Compound Claim for Approved Ingredients
* In the future, Colorado plans to utilize other Rx Override fields.
Conditional – Needed to process claim for approved ingredients when claim is for a compound prescription
If the claim is a compound claim, complete the bottom section of the claim form to indicate each ingredient name, NDC quantity, and cost. Remember that there is a limit of one prescription per claim form.
Ingredient Name Ingredient Name Required when the claim is for a compound prescription
NDC NDC Number of the Ingredient Required when the claim is for a compound prescription
Quantity Metric Decimal Quantity Dispensed Required when the claim is for a compound prescription
Ingredient Cost Submitted   Required when the claim is for a compound prescription

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Electronic Claim Submission Requirements

Interactive claim submission is a real-time exchange of information between the provider and the Health First Colorado program. 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. 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. If the claim is denied, pharmacy benefit manager will send one or more denial reason(s) that identify the problem(s).

Interactive claim submission must comply with Colorado D.0 Requirements. Providers must submit accurate information. The use of inaccurate or false information can result in the reversal of claims.

  • An optional data element means that the user should be prompted for the field but does not have to enter a value.
  • Drug Utilization Review (DUR) information, if applicable, will appear in the message text of the response.
  • Electronic claim submissions must meet timely filing requirements.

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D.0 General Information

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.

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Transactions Supported

Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

Transaction Code Transaction Name
B1 Billing
B3 Rebill
B2 Reversal

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Field Legend for Columns

Payer Usage Column Value Explanation Payer Situation column
MANDATORY M The Field is mandatory for the Segment in the designated Transaction. No
REQUIRED R The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. No
QUALIFIED REQUIREMENT RW "Required when." The situations designated have qualifications for usage ("Required if x", "Not required if y"). Yes

Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template.

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Claim Billing/Claim Rebill Transaction

The following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.

 

Transaction Header Segment Questions Check Claim Billing/Claim Rebill
If Situational, Payer Situation
This segment is always sent X  
Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Payer Issued X  

 

Transaction Header Segment Claim Billing/Claim Rebill
Field # NCPDP Field Name Value Payer Usage Payer Situations
1Ø1-A1 BIN Number 018902 M  
1Ø1-A2 VERSION/RELEASE NUMBER M  
1Ø3-A3 TRANSACTION CODE   M  
1Ø4-A4 PROCESSOR CONTROL NUMBER P303018902 M  
1Ø9-A9 TRANSACTION COUNT   M One transaction for B2 or compound claim; Four allowed for B1 or B3
2Ø2-B2 SERVICE PROVIDER ID QUALIFIER   M Code qualifying the 'Service Provider ID' (Field # 2Ø1-B1)
Ø1 – National Provider Identifier (NPI)
2Ø1-B1 SERVICE PROVIDER ID   M  
4Ø1-D1 DATE OF SERVICE   M  
11Ø-AK SOFTWARE VENDOR/CERTIFICATION ID This will be provided by the provider's software vendor M Assigned when vendor is certified with Magellan Rx Management – If not number is supplied, populate with zeros

 

 

Insurance Segment Questions Check Claim Billing/Claim Rebill
If Situational, Payer Situation
This segment is always sent X  

 

 

Insurance Segment
Segment Identification (111 AM) = "Ø4"
Claim Billing/Claim Rebill
Field # NCPDP Field Name Value Payer Usage Payer Situations
3Ø2-C2 CARDHOLDER ID 12-Byte alpha/numeric ID M CO Medicaid identification number
312-CC CARDHOLDER FIRST NAME   RW  
313-CD CARDHOLDER LAST NAME   RW  
36Ø-2B MEDICAID INDICATOR UNITED STATES AND CANADIAN PROVINCE POSTAL SERVICE RW Imp Guide: Required, if known, when patient has Medicaid coverage.
Payer Requirement: Required in special situations when State issues instructions.
3Ø1-C1 GROUP ID COMEDICAID R  
306-C6 PATIENT RELATIONSHIP CODE 1 = Subscriber R  

 

 

Patient Segment Questions Check Claim Billing/Claim Rebill
If Situational, Payer Situation
This segment is always sent    
This segment is situational X  

 

 

Patient Segment
Segment Identification (111 AM) = "Ø1"
Claim Billing/Claim Rebill
Field # NCPDP Field Name Value Payer Usage Payer Situations
3Ø4-C4 DATE OF BIRTH Format = CCYYMMDD R  
3Ø5-C5 PATIENT GENDER CODE   R  
31Ø-CA PATIENT FIRST NAME   R  
311-CB PATIENT LAST NAME   R  
335-2C PREGNANCY INDICATOR   RW Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility.
384-4X PATIENT RESIDENCE   RW Imp Guide: Required if this field could result in different coverage, pricing, or patient financial responsibility.

 

 

Claim Segment Questions Check Claim Billing/Claim Rebill
If Situational, Payer Situation
This segment is always sent X  
This plan does not accept partial fills X  

 

 

Claim Segment
Segment Identification (111 AM) = "Ø7"
Claim Billing/Claim Rebill
Field # NCPDP Field Name Value Payer Usage Payer Situations
455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER 1 = Rx Billing M  
4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER 12 Bytes M  
456-EN ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER 12 Bytes RW Required for partial fills. This value is the prescription number from the first partial fill.
436-E1 PRODUCT/SERVICE ID QUALIFIER
  • ØØ = Not specified
  • Ø3 = National Drug Code (NDC)
M
  • ØØ must be submitted for compounds
  • 03 for non-compound claims
4Ø7-D7 PRODUCT/SERVICE ID
  • NDC for non-compound claims
  • "Ø" for compound claims
M  
460-ET QUANTITY PRESCRIBED Metric Decimal Quantity RW 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.) Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed
442-E7 QUANTITY DISPENSED Metric Decimal Quantity R  
344-HF QUANTITY INTENDED TO BE DISPENSED Metric Decimal Quantity RW Required for partial fills. Metric decimal quantity of medication that would be dispensed for a full quantity.
4Ø3-D3 FILL NUMBER
  • Ø = Original dispensing
  • 1–5 = Refill number – Number of the replenishment
R  
4Ø5-D5 DAYS SUPPLY   R  
345-HG DAYS SUPPLY INTENDED TO BE DISPENSED   RW Required for partial fills. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity.
4Ø6-D6 COMPOUND CODE
  • 1 = Not a Compound
  • 2 = Compound
R  
4Ø8-D8 DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE
  • Ø = No Product Selection Indicated
  • 1 = Substitution Not Allowed by Prescriber
  • 8 = Substitution Allowed—Generic Drug Not Available in Marketplace
  • 9 = Substitution Allowed by Prescriber but Plan Requests Brand
R Values other than Ø, 1, 08 and 09 will deny. The "Dispense as Written (DAW) Override Codes" table describes the valid scenarios allowable per DAW code.
343-HD DISPENSING STATUS
  • P=Partial
  • C=Complete
RW Required for partial fills. "P" indicates the quantity dispensed is a partial fill. "C" indicates the completion of a partial fill.
414-DE DATE PRESCRIPTION WRITTEN CCYYMMDD R  
457-EP ASSOCIATED PRESCRIPTION/SERVICE DATE CCYYMMDD RW Required for partial fills. Date of service for the Associated Prescription/Service Reference Number (456-EN).
415-DF NUMBER OF REFILLS AUTHORIZED
  • Ø = No refills authorized
  • 1–99 = Authorized Refill number – with 99 being as needed, refills unlimited
R  
419-DJ PRESCRIPTION ORIGIN CODE
  • 1 = Written
  • 2 = Telephone
  • 3 = Electronic
  • 4 = Facsimile
  • 5 = Pharmacy
R  
354-NX SUBMISSION CLARIFICATION CODE COUNT Maximum count of 3 RW*** Required if field # 420-DK is sent
42Ø-DK SUBMISSION CLARIFICATION CODE   RW
  • 8 = Process Compound For Approved Ingredients
  • 9 = Encounters
  • 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)).
3Ø8-C8 OTHER COVERAGE CODE   RW Required for Coordination of Benefits.
OCC 8 is not allowed.
Health First Colorado is always the payer of last resort.
Refer to the Other Coverage Code Quick sheet available in the Pharmacy Billing Procedures and Forms section of the Department's website.
6ØØ-28 UNIT OF MEASURE
  • EA = Each
  • GM = Grams
  • ML = Milliliters
R  
481-DI LEVEL OF SERVICE   RW  
461-EU PRIOR AUTHORIZATION TYPE CODE   RW  
995-E2 ROUTE OF ADMINISTRATION SNOMED CT Value RW Required when Rx is a compound.

 

 

Pricing Segment Questions Check Claim Billing/Claim Rebill
If Situational, Payer Situation
This segment is always sent X  

 

 

Pricing Segment
Segment Identification (111-AM) = "11"
Claim Billing/Claim Rebill
Field # NCPDP Field Name Value Payer Usage Payer Situations
4Ø9-D9 INGREDIENT COST SUBMITTED   R  
412-DC DISPENSING FEE SUBMITTED   RW Required if necessary as component of Gross Amount Due
426-DQ USUAL AND CUSTOMARY CHARGE   R  
43Ø-DU GROSS AMOUNT DUE   R  
423-DN BASIS OF COST DETERMINATION   RW Imp Guide: Required if needed for receiver claim/encounter adjudication.
Ø5 (Acquisition) or Ø8 (34ØB/Disproportionate Share Pricing/Public Health Service required when billing 340B transactions.

 

 

Prescriber Segment Questions Check Claim Billing/Claim Rebill
If Situational, Payer Situation
This segment is always sent X  

 

 

Prescriber Segment
Segment Identification (111-AM) = "Ø3"
Claim Billing/Claim Rebill
Field # NCPDP Field Name Value Payer Usage Payer Situations
466-EZ PRESCRIBER ID QUALIFIER
  • Ø1 = NPI
  • 08 = State License #
  • 12 = DEA
R  
411-DB PRESCRIBER ID Prescriber's individual NPI, CO State
License or DEA
R Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. Claims submitted with the Prescriber State License after 02/25/2017 will deny NCPDP EC 25 – Missing/Invalid Prescriber ID.

 

 

Coordination of Benefits/Other Payments Segment Questions Check Claim Billing/Claim Rebill
If Situational, Payer Situation
This segment is always sent    
This segment is situational X Required only for secondary, tertiary, etc., claims.

 

 

Coordination of Benefits/Other Payments Segment
Segment Identification (111-AM) = "Ø5"
Claim Billing/Claim Rebill
Field # NCPDP Field Name Value Payer Usage Payer Situations
337-4C Coordination of Benefits/Other Payments Count Maximum count of 9 RW  
338-5C Other Payer Coverage Type   RW  
339-6C OTHER PAYER ID QUALIFIER   RW Required if Other Payer ID (Field # 34Ø-7C) is used
34Ø-7C OTHER PAYER ID   RW Required if COB segment is used.
Other Payer ID = BIN of other payer.
443-E8 OTHER PAYER DATE   RW Required if identification of the Other Payer Date is necessary for claim/encounter adjudication, CCYYMMDD
341-HB OTHER PAYER AMOUNT PAID COUNT Maximum count of 9 RW*** Required on all COB claims with Other Coverage Code of 2 or 4 – Required if Other Payer Amount Paid Qualifier (342-HC) is used.
342-HC OTHER PAYER AMOUNT PAID QUALIFIER   RW
  • Required when there is payment from another source.
  • Required if Other Payer Amount Paid (431-Dv) is used.
431-DV OTHER PAYER AMOUNT PAID   RW Required if other payer has approved payment for some/all of the billing.
Required on all COB claims with Other Coverage Code of 2 or 4.
  • OCC = 2 must submit > $0.01;
  • OCC = 4 must submit = 0.
471-5E OTHER PAYER REJECT COUNT Maximum count of 5. RW*** Required if Other Payer Reject Code (472-6E) is used.
Required on all COB claims with Other Coverage Code of 3.
472-6E OTHER PAYER REJECT CODE   RW Required on all COB claims with Other Coverage Code of 3
353-NR OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT Maximum count of 25 RW*** Required on all COB claims with Other Coverage Code of 2 or 4
351-NP OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER   RW Required if Other Payer patient Responsibility Amount (352-NQ) is submitted.
Payer Requirement: Required if OCC = 4. Colorado will only reimburse for amounts submitted with qualifiers 01, 05, and 07.
  • Ø1 = Amount Applied to Periodic Deductible (517-FH)
  • Ø5 = Amount of Copay (518-FI)
  • Ø6 = Patient Pay Applied to Amount (only if Periodic Prior Payer was still Deductible in NCPDP version
  • Ø7 = Amount of Coinsurance (572-4U)
352-NQ OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT   RW Required for all COB claims with Other Coverage Code of 2 or 4. No blanks allowed

 

 

DUR/PPS Segment Questions Check Claim Billing/Claim Rebill
If Situational, Payer Situation
This segment is always sent    
This segment is situational X 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.

 

 

DUR/PPS Segment
Segment Identification (111-AM) = "Ø8"
Claim Billing/Claim Rebill
Field # NCPDP Field Name Value Payer Usage Payer Situations
473-7E DUR/PPS CODE COUNTER Maximum of 9 occurrences RW*** Required if DUR/PPS Segment is used
439-E4 REASON FOR SERVICE CODE   RW*** Required when needed to communicate DUR information
Allowed Values:
  • DD = Drug-Drug Interaction
  • ER = Early Refill
  • HD = High Dose
  • PG = Pregnancy
44Ø-E5 PROFESSIONAL SERVICE CODE   RW*** Required when needed to communicate DUR information
Allowed Values:
  • MA = Medication Administration – use for vaccine
  • MØ = Prescriber consulted
  • PØ = Patient consulted
  • RØ = Pharmacist consulted other source
441-E6 RESULT OF SERVICE CODE   RW*** Required when needed to communicate DUR information
Allowed Values:
  • 1A = Filled As Is, False Positive
  • 1B = Filled Prescription As Is
  • 1C = Filled, With Different Dose
  • 1D = Filled, With Different Directions
  • 1F = Filled, With Different Quantity
  • 1G = Filled, With Prescriber Approval
  • 2A = Prescription not filled
  • 2B = Not filled, directions clarified

 

Compound Segment Questions Check Claim Billing/Claim Rebill
If Situational, Payer Situation
This segment is always sent    
This segment is situational X It is used for multi-ingredient prescriptions, when each ingredient is reported.

 

Compound Segment
Segment Identification (111-AM) = "10"
Claim Billing/Claim Rebill
Field # NCPDP Field Name Value Payer Usage Payer Situations
45Ø-EF COMPOUND DOSAGE FORM DESCRIPTION CODE   M  
451-EG COMPOUND DISPENSING UNIT FORM INDICATOR   M  
447-EC COMPOUND INGREDIENT COMPONENT COUNT   M Colorado Pharmacy supports up to 25 ingredients
488-RE COMPOUND PRODUCT ID QUALIFIER   M  
489-TE COMPOUND PRODUCT ID   M  
448-ED COMPOUND INGREDIENT QUANTITY   M  
449-EE COMPOUND INGREDIENT DRUG COST   M  

 

**End of Request Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template**

 

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Response Claim Billing/Claim Rebill Payer Sheet Template

Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response

** Start of Response Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template**

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General Information

Payer Name: Magellan Rx Management Date: 02/25/2017
Plan Name/Group Name: Colorado Medicaid BIN: 018902 PCN: P303018902

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Claim Billing/Claim Rebill PAID (or Duplicate of PAID) Response

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.Ø.

 

Response Transaction Header Segment Questions Check Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
This segment is always sent X  

 

Response Transaction Header Segment Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
Field # NCPDP Field Name Value Payer Usage Payer Situations
1Ø2-A2 VERSION/RELEASE NUMBER   M  
1Ø3-A3 TRANSACTION CODE   M  
1Ø9-A9 TRANSACTION COUNT   M  
5Ø1-F1 HEADER RESPONSE STATUS   M  
2Ø2-B2 SERVICE PROVIDER ID QUALIFIER   M  
2Ø1-B1 SERVICE PROVIDER ID   M  
4Ø1-D1 DATE OF SERVICE   M  

 

Response Message Segment Questions Check Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
This segment is always sent    
This segment is situational X Sent if additional information is available from the payer/processor.

 

Response Message Segment
Segment Identification (111-AM) = "2Ø"
Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
Field # NCPDP Field Name Value Payer Usage Payer Situations
5Ø4-F4 MESSAGE   RW Required if text is needed for clarification or detail.

 

Response Insurance Segment Questions Check Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
This segment is always sent    
This segment is situational X Sent if additional information is available from the payer/processor.

 

Response Insurance Segment
Segment Identification (111-AM) = "25"
Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
Field # NCPDP Field Name Value Payer Usage Payer Situations
3Ø1-C1 GROUP ID   RW Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available.

 

Response Patient Segment Questions Check Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
This segment is always sent    
This segment is situational    

 

Response Patient Segment
Segment Identification (111-AM) = "29"
Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
Field # NCPDP Field Name Value Payer Usage Payer Situations
31Ø-CA PATIENT FIRST NAME   RW Required if known.
311-CB PATIENT LAST NAME   RW Required if known.
3Ø4-C4 DATE OF BIRTH   RW Required if known.

 

Response Status Segment Questions Check Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
This segment is always sent X  

 

Response Status Segment
Segment Identification (111-AM) = "21"
Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
Field # NCPDP Field Name Value Payer Usage Payer Situations
112-AN TRANSACTION RESPONSE STATUS   M  
5Ø3-F3 AUTHORIZATION NUMBER   RW Required if needed to identify the transaction.
547-5F APPROVED MESSAGE CODE COUNT   RW Required if Approved Message Code (548-6F) is used.
548-6F APPROVED MESSAGE CODE   RW Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity.
13Ø-UF ADDITIONAL MESSAGE INFORMATION COUNT   RW Required if Additional Message Information (526-FQ) is used.
132-UH ADDITIONAL MESSAGE INFORMATION QUALIFIER   RW Required if Additional Message Information (526-FQ) is used.
526-FQ ADDITIONAL MESSAGE INFORMATION   RW Required when additional text is needed for clarification or detail.
131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY   RW Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F HELP DESK PHONE NUMBER QUALIFIER   RW Required if Help Desk Phone Number (55Ø-8F) is used.
55Ø-8F HELP DESK PHONE NUMBER   RW Required if needed to provide a support telephone number to the receiver.

 

Response Claim Segment Questions Check Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
This segment is always sent X  

 

Response Claim Segment
Segment Identification (111-AM) = "22"
Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
Field # NCPDP Field Name Value Payer Usage Payer Situations
455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER   M  
4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER   M  

 

Response Pricing Segment Questions Check Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
This segment is always sent X  

 

Response Pricing Segment
Segment Identification (111-AM) = "23"
Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
Field # NCPDP Field Name Value Payer Usage Payer Situations
5Ø5-F5 PATIENT PAY AMOUNT   R  
5Ø6-F6 INGREDIENT COST PAID   R  
5Ø7-F7 DISPENSING FEE PAID   RW
  • Required if this value is used to arrive at the final reimbursement.
557-AV TAX EXEMPT INDICATOR   RW
  • Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing.
521-FL INCENTIVE AMOUNT PAID   RW
  • Required if this value is used to arrive at the final reimbursement.
  • Required if Incentive Amount Submitted (438-E3) is greater than zero (Ø).
563-J2 OTHER AMOUNT PAID COUNT   RW
  • Imp Guide: Required if Other Amount Paid (565-J4) is used.
564-J3 OTHER AMOUNT PAID QUALIFIER   RW
  • Imp Guide: Required if Other Amount Paid (565-J4) is used.
565-J4 OTHER AMOUNT PAID   RW
  • Required if this value is used to arrive at the final reimbursement.
  • Required if Other Amount Claimed Submitted (48Ø-H9) is greater than zero (Ø).
566-J5 OTHER PAYER AMOUNT RECOGNIZED   RW
  • Required if this value is used to arrive at the final reimbursement.
  • Required if Other Payer Amount Paid (431-DV) is greater than zero (Ø) and Coordination of Benefits/Other Payments Segment is supported.
5Ø9-F9 TOTAL AMOUNT PAID   R  
522-FM BASIS OF REIMBURSEMENT DETERMINATION   RW
  • Required if Ingredient Cost Paid (5Ø6-F6) is greater than zero (Ø).
  • Required if Basis of Cost Determination (432-DN) is submitted on billing.
512-FC ACCUMULATED DEDUCTIBLE AMOUNT   RW
  • Provided for informational purposes only.
513-FD REMAINING DEDUCTIBLE AMOUNT   RW
  • Provided for informational purposes only.
514-FE REMAINING BENEFIT AMOUNT   RW
  • Provided for informational purposes only.
517-FH AMOUNT APPLIED TO PERIODIC DEDUCTIBLE   RW
  • Required if Patient Pay Amount (5Ø5-F5) includes deductible
518-FI AMOUNT OF COPAY   RW
  • Required if Patient Pay Amount (5Ø5-F5) includes co-pay as patient financial responsibility.
52Ø-FK AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM   RW
  • Required if Patient Pay Amount (5Ø5-F5) includes amount exceeding periodic benefit maximum.
572-4U AMOUNT OF COINSURANCE   RW
  • Required if Patient Pay Amount (5Ø5-F5) includes coinsurance as patient financial responsibility.
128-UC SPENDING ACCOUNT AMOUNT REMAINING   RW
  • 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.
129-UD HEALTH PLAN-FUNDED ASSISTANCE AMOUNT   RW
  • Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (5Ø5-F5). The resulting Patient Pay Amount (5Ø5-F5) must be greater than or equal to zero.

 

Response DUR/PPS Segment Questions Check Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
This segment is always sent    
This segment is situational X Sent when DUR intervention is encountered during claim processing.

 

Response DUR/PPS Segment
Segment Identification (111-AM) = "24"
Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
Field # NCPDP Field Name Value Payer Usage Payer Situations
567-J6 DUR/PPS RESPONSE CODE COUNTER   RW
  • Required if Reason for Service Code (439-E4) is used.
439-E4 REASON FOR SERVICE CODE   RW
  • Required if utilization conflict is detected.
528-FS CLINICAL SIGNIFICANCE CODE   RW
  • Required if needed to supply additional information for the utilization conflict.
529-FT OTHER PHARMACY INDICATOR   RW
  • Required if needed to supply additional information for the utilization conflict.
53Ø-FU PREVIOUS DATE OF FILL   RW
  • Required if needed to supply additional information for the utilization conflict.
  • Required if Quantity of Previous Fill (531-FV) is used.
531-FV QUANTITY OF PREVIOUS FILL   RW
  • Required if needed to supply additional information for the utilization conflict.
  • Required if Previous Date Of Fill (53Ø-FU) is used.
532-FW DATABASE INDICATOR   RW
  • Required if needed to supply additional information for the utilization conflict.
533-FX OTHER PRESCRIBER INDICATOR   RW
  • Required if needed to supply additional information for the utilization conflict.
544-FY DUR FREE TEXT MESSAGE   RW
  • Required if needed to supply additional information for the utilization conflict.
57Ø-NS DUR ADDITIONAL TEXT   RW
  • Required if needed to supply additional information for the utilization conflict.

 

Response Coordination of Benefits/Other Payers Segment Questions Check Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
If Situational, Payer Situation
This segment is always sent    
This segment is situational X Sent when Other Health Insurance (OHI) is encountered during claims processing.

 

Response Coordination of Benefits/Other Payers Segment
Segment Identification (111-AM) = "28"
Claim Billing/Claim Rebill
Accepted/Paid (or Duplicate of Paid)
Field # NCPDP Field Name Value Payer Usage Payer Situations
355-NT OTHER PAYER ID COUNT   RW  
338-5C OTHER PAYER COVERAGE TYPE   RW  
339-6C OTHER PAYER ID QUALIFIER   RW
  • Required if Other Payer ID (34Ø-7C) is used.
34Ø-7C OTHER PAYER ID   RW
  • Required if other insurance information is available for coordination of benefits.
991-MH OTHER PAYER PROCESSOR CONTROL NUMBER   RW
  • Required if other insurance information is available for coordination of benefits.
356-NU OTHER PAYER CARDHOLDER ID   RW
  • Required if other insurance information is available for coordination of benefits.
992-MJ OTHER PAYER GROUP ID   RW
  • Required if other insurance information is available for coordination of benefits.
142-UV OTHER PAYER PERSON CODE   RW
  • Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer.
127-UB OTHER PAYER HELP DESK PHONE NUMBER   RW
  • Required if needed to provide a support telephone number of the other payer to the receiver.
143-UW OTHER PAYER PATIENT RELATIONSHIP CODE   RW
  • Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer.

 

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Claim Billing/Claim Rebill Accepted/Rejected Response

 

Response Transaction Header Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected
If Situational, Payer Situation
This segment is always sent X  

 

Response Transaction Header Segment Claim Billing/Claim Rebill Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
1Ø2-A2 VERSION/RELEASE NUMBER   M  
1Ø3-A3 TRANSACTION CODE   M  
1Ø9-A9 TRANSACTION COUNT   M  
5Ø1-F1 HEADER RESPONSE STATUS   M  
2Ø2-B2 SERVICE PROVIDER ID QUALIFIER   M  
2Ø1-B1 SERVICE PROVIDER ID   M  
4Ø1-D1 DATE OF SERVICE   M  

 

Response Transaction Header Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected
If Situational, Payer Situation
This segment is always sent    
This segment is situational X Required if text is needed for clarification or detail.

 

Response Message Segment
Segment Identification (111-AM) = "2Ø"
Claim Billing/Claim Rebill Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
5Ø4-F4 MESSAGE   RW  

 

Response Insurance Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected
If Situational, Payer Situation
This segment is always sent X  
This segment is situational    

 

Response Insurance Segment
Segment Identification (111-AM) = "25"
Claim Billing/Claim Rebill Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
3Ø1-C1 GROUP ID   R
  • Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available.
  • Required to identify the actual group that was used when multiple group coverage exist.
3Ø2-C2 CARDHOLDER ID   RW
  • Required if the identification to be used in future transactions is different than what was submitted on the request.

 

Response Patient Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected
If Situational, Payer Situation
This segment is always sent    
This segment is situational X Sent when known by plan

 

Response Patient Segment
Segment Identification (111-AM) = "29"
Claim Billing/Claim Rebill Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
31Ø-CA PATIENT FIRST NAME   RW
  • Required if known.
311-CB PATIENT LAST NAME   RW
  • Required if known.
3Ø4-C4 DATE OF BIRTH   RW
  • Required if known.

 

Response Status Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected
If Situational, Payer Situation
This segment is always sent X  

 

Response Status Segment
Segment Identification (111-AM) = "21"
Claim Billing/Claim Rebill Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
112-AN TRANSACTION RESPONSE STATUS   M  
5Ø3-F3 AUTHORIZATION NUMBER    
  • Required if needed to identify the transaction.
51Ø-FA REJECT COUNT   R  
511-FB REJECT CODE   R  
546-4F REJECT FIELD OCCURRENCE INDICATOR   RW
  • Required if a repeating field is in error, to identify repeating field occurrence.
13Ø-UF ADDITIONAL MESSAGE INFORMATION COUNT   RW
  • Required if Additional Message Information (526-FQ) is used.
132-UH ADDITIONAL MESSAGE INFORMATION QUALIFIER   RW
  • Required if Additional Message Information (526-FQ) is used.
526-FQ ADDITIONAL MESSAGE INFORMATION   RW
  • Required when additional text is needed for clarification or detail.
131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY   RW
  • Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F HELP DESK PHONE NUMBER QUALIFIER   RW
  • Required if Help Desk Phone Number (55Ø-8F) is used.
55Ø-8F HELP DESK PHONE NUMBER   RW
  • Required if needed to provide a support telephone number to the receiver.

 

Response Claim Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected
If Situational, Payer Situation
This segment is always sent X  

 

Response Claim Segment
Segment Identification (111-AM) = "22"
Claim Billing/Claim Rebill Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER   M Imp Guide: For Transaction Code of "B1," in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).
4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER   M  

 

Response DUR/PPS Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected
If Situational, Payer Situation
This segment is always sent    
This segment is situational X Sent when DUR intervention is encountered during claim adjudication.

 

Response DUR/PPS Segment
Segment Identification (111-AM) = "24"
Claim Billing/Claim Rebill Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
567-J6 DUR/PPS RESPONSE CODE COUNTER Maximum 9 occurrences supported. RW
  • Required if Reason for Service Code (439-E4) is used.
439-E4 REASON FOR SERVICE CODE   RW
  • Required if utilization conflict is detected.
528-FS CLINICAL SIGNIFICANCE CODE   RW
  • Required if needed to supply additional information for the utilization conflict.
529-FT OTHER PHARMACY INDICATOR   RW
  • Required if needed to supply additional information for the utilization conflict.
53Ø-FU PREVIOUS DATE OF FILL   RW
  • Required if needed to supply additional information for the utilization conflict.
  • Required if Quantity of Previous Fill (531-FV) is used.
531-FV QUANTITY OF PREVIOUS FILL   RW
  • Required if needed to supply additional information for the utilization conflict.
  • Required if Previous Date of Fill (53Ø-FU) is used.
532-FW DATABASE INDICATOR   RW
  • Required if needed to supply additional information for the utilization conflict.
533-FX OTHER PRESCRIBER INDICATOR   RW
  • Required if needed to supply additional information for the utilization conflict.
544-FY DUR FREE TEXT MESSAGE   RW
  • Required if needed to supply additional information for the utilization conflict.
57Ø-NS DUR ADDITIONAL TEXT   RW
  • Required if needed to supply additional information for the utilization conflict.

 

Response Prior Authorization Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected
If Situational, Payer Situation
This segment is always sent    
This segment is situational X Sent when claim adjudication outcome requires subsequent PA number for payment

 

Response Prior Authorization Segment
Segment Identification (111-AM) = "26"
Claim Billing/Claim Rebill Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
498-PY PRIOR AUTHORIZATION NUMBER–ASSIGNED   RW Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim.

 

Response Coordination of Benefits/Other Payers Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected
If Situational, Payer Situation
This segment is always sent    
This segment is situational X Sent when Other Health Insurance (OHI) is encountered during claim processing.

 

Response Coordination of Benefits/Other Payers Segment
Segment Identification (111-AM) = "28"
Claim Billing/Claim Rebill Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
355-NT OTHER PAYER ID COUNT   RW  
338-5C OTHER PAYER COVERAGE TYPE   RW  
339-6C OTHER PAYER ID QUALIFIER   RW Required if Other Payer ID (34Ø-7C) is used.
34Ø-7C OTHER PAYER ID   RW Required if other insurance information is available for coordination of benefits.
991-MH OTHER PAYER PROCESSOR CONTROL NUMBER   RW Required if other insurance information is available for coordination of benefits.
356-NU OTHER PAYER CARDHOLDER ID   RW Required if other insurance information is available for coordination of benefits.
992-MJ OTHER PAYER GROUP ID   RW Required if other insurance information is available for coordination of benefits.
142-UV OTHER PAYER PERSON CODE   RW Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer.
127-UB OTHER PAYER HELP DESK PHONE NUMBER   RW Required if needed to provide a support telephone number of the other payer to the receiver.
143-UW OTHER PAYER PATIENT RELATIONSHIP CODE   RW Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer.

 

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Claim Billing/Claim Rebill Rejected/Rejected Response

 

Response Transaction Header Segment Questions Check Claim Billing/Claim Rebill Rejected/Rejected
If Situational, Payer Situation
This segment is always sent X  

 

Response Transaction Header Segment Claim Billing/Claim Rebill Rejected/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
1Ø2-A2 VERSION/RELEASE NUMBER   M  
1Ø3-A3 TRANSACTION CODE   M  
1Ø9-A9 TRANSACTION COUNT   M  
5Ø1-F1 HEADER RESPONSE STATUS   M  
2Ø2-B2 SERVICE PROVIDER ID QUALIFIER   M  
2Ø1-B1 SERVICE PROVIDER ID   M  
4Ø1-D1 DATE OF SERVICE   M  

 

Response Message Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected
If Situational, Payer Situation
This segment is always sent    
This segment is situational X  

 

Response Message Segment
Segment Identification (111-AM) = "2Ø"
Claim Billing/Claim Rebill Rejected/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
5Ø4-F4 MESSAGE   RW
  • Required if text is needed for clarification or detail.

 

Response Status Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected
If Situational, Payer Situation
This segment is always sent X  

 

Response Status Segment
Segment Identification (111-AM) = "21"
Claim Billing/Claim Rebill Rejected/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
112-AN TRANSACTION RESPONSE STATUS   M  
5Ø3-F3 AUTHORIZATION NUMBER   RW
  • Required if needed to identify the transaction.
51Ø-FA REJECT COUNT   R  
511-FB REJECT CODE   R  
546-4F REJECT FIELD OCCURRENCE INDICATOR   RW
  • Required if a repeating field is in error, to identify repeating field occurrence.
13Ø-UF ADDITIONAL MESSAGE INFORMATION COUNT   RW
  • Required if Additional Message Information (526-FQ) is used.
132-UH ADDITIONAL MESSAGE INFORMATION QUALIFIER   RW
  • Required if Additional Message Information (526-FQ) is used.
526-FQ ADDITIONAL MESSAGE INFORMATION   RW
  • Required when additional text is needed for clarification or detail.
131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY   RW
  • Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F HELP DESK PHONE NUMBER QUALIFIER   RW
  • Required if Help Desk Phone Number (55Ø-8F) is used.
55Ø-8F HELP DESK PHONE NUMBER   RW
  • Required if needed to provide a support telephone number to the receiver.

 

 

** End of Response Claim Billing/Claim Rebill (B1/B3) Payer Sheet Template**

 

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NCPDP Version D.0 Claim Reversal Template

Request Claim Reversal Payer Sheet Template

 

** Start of Request Claim Reversal (B2) Payer Sheet Template**

 

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General Information

Payer Name: Magellan Rx Management Date: 02/25/2017
Plan Name/Group Name: Colorado Medicaid BIN: 018902 PCN: P303018902

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Claim Reversal Transaction

The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.

Transaction Header Segment Questions Check Claim Reversal
If Situational, Payer Situation
This segment is always sent X  
Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Payer Issued X  

 

Transaction Header Segment Claim Reversal
Field # NCPDP Field Name Value Payer Usage Payer Situations
1Ø1-A1 BIN NUMBER 018902 M  
1Ø2-A2 VERSION/RELEASE NUMBER   M  
1Ø3-A3 TRANSACTION CODE   M  
1Ø4-A4 PROCESSOR CONTROL NUMBER P303018902 M  
1Ø9-A9 TRANSACTION COUNT   M  
2Ø2-B2 SERVICE PROVIDER ID QUALIFIER   M  
2Ø1-B1 SERVICE PROVIDER ID   M  
4Ø1-D1 DATE OF SERVICE   M  
11Ø-AK SOFTWARE VENDOR/CERTIFICATION ID This will be provided by the provider's software vendor M If no number is supplied, populate with zeros

 

 

Insurance Segment Questions Check Claim Reversal
If Situational, Payer Situation
This segment is always sent X  
This segment is situational    

 

 

Insurance Segment
Segment Identification (111-AM) = "Ø4"
Claim Reversal
Field # NCPDP Field Name Value Payer Usage Payer Situations
3Ø2-C2 CARDHOLDER ID   M  
3Ø1-C1 GROUP ID   RW
  • Required if needed to match the reversal to the original billing transaction.
3Ø6-C6 PATIENT RELATIONSHIP CODE   R  

 

 

Claim Segment Questions Check Claim Reversal
If Situational, Payer Situation
This segment is always sent X  

 

 

Claim Segment
Segment Identification (111-AM) = "Ø7"
Claim Reversal
Field # NCPDP Field Name Value Payer Usage Payer Situations
455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER   M  
4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER   M  
436-E1 PRODUCT/SERVICE ID QUALIFIER   M  
4Ø7-D7 PRODUCT/SERVICE ID   M  
4Ø3-D3 FILL NUMBER   R
  • Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (4Ø2-D2) occur on the same day.
3Ø8-C8 OTHER COVERAGE CODE   RW
  • Required if needed by receiver to match the claim that is being reversed.

 

 

Pricing Segment Questions Check Claim Reversal
If Situational, Payer Situation
This segment is always sent    
This segment is situational X  

 

 

Pricing Segment
Segment Identification (111-AM) = "11"
Claim Reversal
Field # NCPDP Field Name Value Payer Usage Payer Situations
438-E3 INCENTIVE AMOUNT SUBMITTED   RW
  • Required if this field could result in contractually agreed upon payment.
43Ø-DU GROSS AMOUNT DUE   RW
  • Required if this field could result in contractually agreed upon payment.

 

 

Coordination of Benefits/Other Payments Segment Questions Check Claim Reversal
If Situational, Payer Situation
This segment is always sent    
This segment is situational X Required only for secondary, tertiary, etc., claims.
Scenario 3 – Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs) X OCC codes 0, 1, 2, 3, and 4 Supported (no co-pay only billing allowed)

 

 

Coordination of Benefits/Other Payments Segment
Segment Identification (111-AM) = "Ø5"
Claim Reversal
Field # NCPDP Field Name Value Payer Usage Payer Situations
337-4C COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT   RW  
338-5C Other Payer Coverage Type   RW  
339-6C OTHER PAYER ID QUALIFIER   RW Required if Other Payer ID (Field # 34Ø-7C) is used
34Ø-7C OTHER PAYER ID   RW Required if COB segment is used
443-E8 OTHER PAYER DATE   RW Required if identification of the Other Payer Date is necessary for claim/encounter adjudication.
341-HB OTHER PAYER AMOUNT PAID COUNT   RW Required if Other Payer Amount Paid Qualifier (342-HC) is used.
342-HC OTHER PAYER AMOUNT PAID QUALIFIER   RW Required when there is payment from another source. Required on all COB claims with Other Coverage Code of 2
  • "Ø7" is the only accepted value.
431-DV OTHER PAYER AMOUNT PAID   RW Required if other payer has approved payment for some/all of the billing.
471-5E OTHER PAYER REJECT COUNT   RW*** Required on all COB claims with Other Coverage Code of 3.
472-6E OTHER PAYER REJECT CODE   RW Required on all COB claims with Other Coverage Code of 3
353-NR OTHER PAYER – PATIENT RESPONSIBILITY AMOUNT COUNT   R Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used
351-NP OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFER   R Required if Other Payer-Patient Responsibility Amount (352-NQ) is used352-NQ
352-NQ OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT   R Required OCC = 2 or 4

 

** End of Request Claim Reversal (B2) Payer Sheet Template**

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Response Claim Reversal Payer Sheet Template

Claim Reversal Accepted/Approved Response

** Start of Claim Reversal Response (B2) Payer Sheet Template**

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General Information

Payer Name: Magellan Rx Management Date: 02/25/2017
Plan Name/Group Name: Colorado Medicaid BIN: 018902 PCN: P303018902

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Claim Reversal Accepted/Approved Response

The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.

Response Transaction Header Segment Questions Check Claim Reversal – Accepted/Approved If Situational, Payer Situation
This segment is always sent    
This segment is situational X Required only for secondary, tertiary, etc., claims.
Response Transaction Header Segment Claim Reversal – Accepted/Approved
Field # NCPDP Field Name Value Payer Usage Payer Situations
1Ø2-A2 VERSION/RELEASE NUMBER   M  
1Ø3-A3 TRANSACTION CODE   M  
1Ø9-A9 TRANSACTION COUNT   M  
5Ø1-F1 HEADER RESPONSE STATUS   M  
2Ø2-B2 SERVICE PROVIDER ID QUALIFIER   M  
2Ø1-B1 SERVICE PROVIDER ID   M  
4Ø1-D1 DATE OF SERVICE   M  

 

Response Message Segment Questions Check Claim Reversal - Accepted/Approved
If Situational, Payer Situation
This segment is always sent    
This segment is situational X  

 

 

Response Message Segment
Segment Identification (111-AM) = "2Ø"
Claim Reversal - Accepted/Approved
Field # NCPDP Field Name Value Payer Usage Payer Situations
5Ø4-F4 MESSAGE   RW
  • Required if text is needed for clarification or detail.

 

 

Response Status Segment Questions Check Claim Reversal - Accepted/Approved
If Situational, Payer Situation
This segment is always sent    

 

 

Response Status Segment
Segment Identification (111-AM) = "21"
Claim Reversal – Accepted/Approved
Field # NCPDP Field Name Value Payer Usage Payer Situations
112-AN TRANSACTION RESPONSE STATUS   M  
5Ø3-F3 AUTHORIZATION NUMBER   RW
  • Required if needed to identify the transaction.
547-5F APPROVED MESSAGE CODE COUNT   RW
  • Required if Approved Message Code (548-6F) is used.
548-6F APPROVED MESSAGE CODE   RW
  • Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity.
13Ø-UF ADDITIONAL MESSAGE INFORMATION COUNT   RW
  • Required if Additional Message Information (526-FQ) is used.
132-UH ADDITIONAL MESSAGE INFORMATION QUALIFIER   RW
  • Required if Additional Message Information (526-FQ) is used.
526-FQ ADDITIONAL MESSAGE INFORMATION   RW
  • Required when additional text is needed for clarification or detail.
131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY   RW
  • Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
49-7F HELP DESK PHONE NUMBER QUALIFIER   RW
  • Required if Help Desk Phone Number (55Ø-8F) is used.
55Ø-8F HELP DESK PHONE NUMBER   RW
  • Required if needed to provide a support telephone number to the receiver.

 

 

Response Claim Segment Questions Check Claim Reversal - Accepted/Approved
If Situational, Payer Situation
This segment is always sent X  

 

 

Response Claim Segment
Segment Identification (111-AM) = "22"
Claim Reversal – Accepted/Approved
Field # NCPDP Field Name Value Payer Usage Payer Situations
455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER   M For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).
4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER   M  

 

Response Pricing Segment Questions Check Claim Reversal - Accepted/Approved
If Situational, Payer Situation
This segment is always sent    
This segment is situational X Sent if reversal results in generation of pricing detail.

 

Response Pricing Segment
Segment Identification (111-AM) = "22"
Claim Reversal – Accepted/Approved
Field # NCPDP Field Name Value Payer Usage Payer Situations
521-FL INCENTIVE AMOUNT PAID   RW
  • Required if this field is reporting a contractually agreed upon payment.
5Ø9-F9 TOTAL AMOUNT PAID   RW
  • Required if any other payment fields sent by the sender.

 

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Claim Reversal Accepted/Rejected Response

Response Transaction Header Segment Questions Check Claim Reversal - Accepted/Approved
If Situational, Payer Situation
This segment is always sent X  

 

Response Transaction Header Segment Claim Reversal – Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
1Ø2-A2 VERSION/RELEASE NUMBER   M  
1Ø3-A3 TRANSACTION CODE   M  
1Ø9-A9 TRANSACTION COUNT   M  
5Ø1-F1 HEADER RESPONSE STATUS   M  
2Ø2-B2 SERVICE PROVIDER ID QUALIFIER   M  
2Ø1-B1 SERVICE PROVIDER ID   M  
4Ø1-D1 DATE OF SERVICE   M  

 

 

Response Message Segment Questions Check Claim Reversal - Accepted/Rejected
If Situational, Payer Situation
This segment is always sent    
This segment is situational X  

 

 

Response Message Segment
Segment Identification (111-AM) = "2Ø"
Claim Reversal - Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
5Ø4-F4 MESSAGE   RW
  • Required if text is needed for clarification or detail.

 

 

Response Status Segment Questions Check Claim Reversal - Accepted/Rejected
If Situational, Payer Situation
This segment is always sent X  

 

 

Response Status Segment
Segment Identification (111-AM) = "21"
Claim Reversal – Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
112-AN TRANSACTION RESPONSE STATUS   M  
5Ø3-F3 AUTHORIZATION NUMBER   R  
51Ø-FA REJECT COUNT   R  
511-FB REJECT CODE   R  
546-4F REJECT FIELD OCCURRENCE INDICATOR   RW
  • Required if a repeating field is in error, to identify repeating field occurrence.
13Ø-UF ADDITIONAL MESSAGE INFORMATION COUNT   RW
  • Required if Additional Message Information (526-FQ) is used.
132-UH ADDITIONAL MESSAGE INFORMATION QUALIFIER   RW
  • Required if Additional Message Information (526-FQ) is used.
526-FQ ADDITIONAL MESSAGE INFORMATION   RW
  • Required when additional text is needed for clarification or detail.
131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY   RW
  • Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F HELP DESK PHONE NUMBER QUALIFIER   RW
  • Required if Help Desk Phone Number (55Ø-8F) is used.
55Ø-8F HELP DESK PHONE NUMBER   RW
  • Required if needed to provide a support telephone number to the receiver.

 

 

Response Claim Segment Questions Check Claim Reversal - Accepted/Rejected
If Situational, Payer Situation
This segment is always sent X  

 

 

Response Claim Segment
Segment Identification (111-AM) = "22"
Claim Reversal – Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER   M For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing).
4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER   M  

 

 

Coordination of Benefits/Other Payments Segment Questions Check Claim Reversal
If Situational, Payer Situation
This segment is always sent    
This segment is situational X  

 

 

Coordination of Benefits/Other Payments
Segment Identification (111-AM) = "Ø5"
Claim Reversal – Accepted/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
337-4C COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT   RW  
338-5C OTHER PAYER COVERAGE TYPE   RW  

 

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Claim Reversal Rejected/Rejected Response

Response Transaction Header Segment Questions Check Claim Reversal – Rejected/Rejected
If Situational, Payer Situation
This segment is always sent X  

 

Response Transaction Header Segment Claim Reversal – Rejected/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
1Ø2-A2 VERSION/RELEASE NUMBER   M  
1Ø3-A3 TRANSACTION CODE   M  
1Ø9-A9 TRANSACTION COUNT   M  
5Ø1-F1 HEADER RESPONSE STATUS   M  
2Ø2-B2 SERVICE PROVIDER ID QUALIFIER   M  
2Ø1-B1 SERVICE PROVIDER ID   M  
4Ø1-D1 DATE OF SERVICE   M  

 

 

Response Message Segment Questions Check Claim Reversal – Rejected/Rejected
If Situational, Payer Situation
This segment is always sent    
This segment is situational X  

 

 

Response Message Segment
Segment Identification (111-AM) = "2Ø"
Claim Reversal - Rejected/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
5Ø4-F4 MESSAGE   RW
  • Imp. Guide: Required if text is needed for clarification or detail.
  • Payer Requirement: Same as Imp Guide

 

 

 

Response Status Segment Questions Check Claim Reversal - Rejected/Rejected
If Situational, Payer Situation
This segment is always sent X  

 

 

 

Response Status Segment
Segment Identification (111-AM) = "21"
Claim Reversal – Rejected/Rejected
Field # NCPDP Field Name Value Payer Usage Payer Situations
112-AN TRANSACTION RESPONSE STATUS   M  
5Ø3-F3 AUTHORIZATION NUMBER   R  
51Ø-FA REJECT COUNT   R  
511-FB REJECT CODE   R  
546-4F REJECT FIELD OCCURRENCE INDICATOR   RW
  • Required if a repeating field is in error, to identify repeating field occurrence.
13Ø-UF ADDITIONAL MESSAGE INFORMATION COUNT   RW
  • Required if Additional Message Information (526-FQ) is used.
132-UH ADDITIONAL MESSAGE INFORMATION QUALIFIER   RW
  • Required if Additional Message Information (526-FQ) is used.
526-FQ ADDITIONAL MESSAGE INFORMATION   RW
  • Required when additional text is needed for clarification or detail.
131-UG ADDITIONAL MESSAGE INFORMATION CONTINUITY   RW
  • Required if and only if current repetition of Additional Message Information (526-FQ) is used, another populated repetition of Additional Message Information (526-FQ) follows it, and the text of the following message is a continuation of the current.
549-7F HELP DESK PHONE NUMBER QUALIFIER   RW
  • Required if Help Desk Phone Number (55Ø-8F) is used.
55Ø-8F HELP DESK PHONE NUMBER   RW
  • Required if needed to provide a support telephone number to the receiver.

 

 

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Revision History

Revision date Additions/Changes
08/26/2016 Updates made throughout related to the POS implementation under Magellan Rx Management.
09/26/2016 Updates made throughout related to the POS implementation under Magellan Rx Management.
01/05/2017 Updates made to DAW requirements
02/03/2017 Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request.
Update to URL posted under Restricted Products section per Cathy T. request.
02/03/2017 Medication Requiring PAR - Update to Over-the-counter products.
Refill Too Soon Policy - Update to refill too soon policy for Synagis.
Restricted Products – updated to DESI coverage requirements. Benzodiazepines removed from coverage list.
Billing Information - gaps or spacing removed.
Instructions for Completing the Pharmacy Claim Form – Client's Medicaid ID field length changed to 7-characters
D.0 General Information – updated based on new POS go-live date.
Cover Page – updated
02/08/2017 Instructions for Completing the Pharmacy Claim Form – update to Prescriber ID, ID Qualifier and Product ID Qualifier.
05/23/2017 Updated Lost/Stolen/Damaged/Vacation Prescriptions section – police report is no longer required for Stolen Medications;
Updated DAW chart with the following note for DAW 9: Note: For products that are Brand Name Required, DAW 9 will be allowed;
Added B2 to the Transactions Supported Chart;
Added the following to 351-NP Other Payer Patient Responsibility Amount Qualifier: Ø6 = Patient Pay Applied to Amount (only if Periodic Prior Payer was still Deductible in NCPDP version
08/28/2017 PAR Process: Updated notification letter section
RTS Policy: Updated accumulation language
DAW 8: Updated section that applies to drug list
340B Claims Processing: Added chart for values
Single Agent Antihistamines: Combination product with decongestant language added
Timely Filing: Remittance Advice (RA) language updated
Appealing: Fax number added to section
Reuse of Rx Numbers: New section added
10/13/2017 Partial Fills and/or Prescription: Updated partial fill criteria
340B Claims Processing: Updated acquisition cost value
11/8/2017 Updated contact information on page 15, to include Magellan's helpdesk info
11/20/2017 Update verbiage in Co-pay section
08/22/2018 Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles.
DAW Codes: Updated "Dispense as Written (DAW) Override Code" table and updated payor sheets to reflect allowable DAW codes.
Green highlighting: Removed highlighting throughout document on previous new additions.
3/27/2020 Updated verbiage in Counseling section
5/6/2020 Added Temporary COVID section, updated Provider Web Portal link
6/4/2020 Converted into web page.
7/1/2020 Updated verbiage to include the NCPDP D.0 guidelines for field 460-ET
7/8/2020 Updated DAW Codes: Updated “Dispense as Written (DAW) Override Code” table
8/20/2020 Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions.
9/25/2020 Updated COVID Early Refill Policy
11/17/2020 Updated Partial Fill Section to read Incremental Fills and/or Prescription Splitting