Effective as of July 1, 2021 NCPDP Telecommunication Standard Version D. NCPDP Data Dictionary Version Date August of 2007 NCPDP External Code List Version Date October 15, 2020 Contact/Information Source www.medimpact.com SNO-MED is a required field for compounds - the route of administration is required-NCPDP # ROUTE OF ADMINISTRATION (Field # 995-E2). The following NCPDP fields below will be required on 340B transactions. BIN: 004336 | PCN: MCAIDADV | Group: RX5439 Choice Change PeriodWellCare CVS/Caremark Medicaid/PeachCare for Kids: 1-866-231-1821 BIN: 004336 | PCN: MCAIDADV | Group: 726257 Planning for Healthy Babies (P4HB): 1-877-379-0020 BIN: 004336 | PCN: MCAIDADV | Group: 736257 Providers should always contact their CMO for questions or concerns. 'https:' : 'http:') + These medications (e.g., Paxlovid) still need to be billed to Colorado Medicaid, even though they are free of cost, and the claim requirements for billing free medications is outlined below: 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. Information regarding methods to determine a Medicaid member's eligibility will be included in a subsequent Medicaid Update article. Benefits under STAR. These records must be maintained for at least seven (7) years. Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. In addition, some products are excluded from coverage and are listed in the Restricted Products section. 02 = Amount Attributed to Product Selection/Brand Drug (134-UK) All necessary forms should be submitted to Magellan Rx Management at: There are four exceptions to the 120-day rule: Each of these exceptions is detailed below along with the specific instructions for submitting claims. Required if Additional Message Information (526-FQ) is used. Information on DHS Applications and Forms grouped by category. Licensing information for Adult Foster Care and Homes for the Aged, Child Day Care Facilities, Child Caring Institutions, Children's Foster Care Homes, Child Placing Agencies, Juvenile Court Operated Facilities and Children's or Adult Foster Care Camps. Required for 340B Claims. The following categories of members are exempt from co-pay: Effective July 1, 2022, the following changes occurred as it relates to family planning and family planning-related pharmacy benefits. Members can receive a brand name drug without a PAR if: Members may receive a brand name drug with a PAR if: The pharmacy Prior Authorization Form is available on the Pharmacy Resources web page of the Department's website. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. The use of inaccurate or false information can result in the reversal of claims. Scheduled II drugs will deny NCPDP ET M/I Quantity Prescribed. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. Click here for the second page (H2001 - H3563) , third page (H3572 - H5325) , fourth page (H5337 - H7322) , fifth page (H7323 - H9686) and sixth page (H9699 - S9701). NC MedicaidClinical Section Phone: 919-855-4260Fax: 919-715-1255Email: medicaid.pdl@dhhs.nc.gov, This page was last modified on 01/05/2023, An official website of the State of North Carolina, Outpatient Pharmacy Policies(9,9A,9B, 9Dand9E), Submit Proposed Clinical Policy Changes to the PDL, Preferred Drug List (PDL) and Supplemental Rebate Program Annual Report SFY 2021, NADAC Weekly Files and NADAC Week to Week Comparison files, NADAC Methodology (Part II) and NADAC Help Desk contact information, Pharmacy Provider Generic Dispensing Rate Report, Diabetic Testing and CGM Supplies - Oct. 13, 2022 - EXCEL, Diabetic Testing and CGM Supplies - Oct. 13, 2022 - PDF, Diabetic Testing and CGM Supplies - Sep. 7, 2022 - EXCEL, Diabetic Testing and CGM Supplies - Sep. 7, 2022 - PDF, Diabetic Testing and CGM Supplies - July, 15, 2022 - EXCEL, Diabetic Testing and CGM Supplies - July, 15, 2022 - PDF, Diabetic Testing Supplies & CGM - June 29, 2022 - EXCEL, Diabetic Testing Supplies & CGM - June 29, 2022 - PDF, State Maximum Allowable Cost (SMAC) Pricing Inquiry Worksheet, North Carolina Multidisciplinary Collaboration on Opioid Use and Misuse, Preferred Drug List Opioid Analgesics and Combination Therapy Daily MME, Prior Approval Criteria for Opioid Analgesics, NC Medicaid Opioid Safety - STOP Act Crosswalk (June 2018), Provider Considerations for Tapering of Opioids. Indicates that the drug was purchased through the 340B Drug Pricing Program. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. Pharmacies can also check a member's enrollment with a West Virginia Medicaid MCO by calling 888-483-0793 Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. 2.1 Application, Determination of Eligibility and Furnishing Medicaid 2.2 Coverage and Conditions of Eligibility 2.3 Residence 2.4 Blindness 2.5 Disability 2.6 Financial Eligibility 2.7 Medicaid Furnished Out of State 3.0 SERVICES: GENERAL PROVISIONS 3.1 Amount, Duration, and Scope of Services 3.2 Coordination of Medicaid with Medicare Part B Please refer to the October 2020 Medicaid Update article titled Attention: Pharmacies Durable Medical Equipment, Prosthetics, Orthotics, and Supply Providers, and Prescribers That are Not Enrolled in Medicaid Fee-for-Service. Health First Colorado is the payer of last resort. Enrolling in Health First Colorado as an OPR provider: If an OPR prescriber does not wish to enroll with Health First Colorado they must refer their patients to an enrolled prescriber, otherwise claims will deny. This publication provides information regarding the Medicaid Pharmacy Carve-Out, a Medicaid Redesign Team (MRT) II initiative to transition the pharmacy benefit from managed care to the Medicaid Fee-for-Service (FFS) Pharmacy Program. Bank Identification Number (BIN) and Processor Control Number (PCN): For submitting FFS claims to Medicaid via NCPDP D.0, the BIN number is required in field 101-A1 and is "004740". Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim. The CSHCN Services Program is a separate program from Medicaid and has separate funding sources. 4 MeridianRx 2020 Payer Sheet v1 (Revised 9/1/2020) Version Information Version Date Page Field Notes 1.0 1/1/2017 Payer Sheet for 2017 2.0 1/1/2018 Payer Sheet for 2018 . All pharmacy PARs must be telephoned, faxed, or submitted via Real Time Prior Authorization via EHR, by the prescribing physician or physician's agent to the Pharmacy Benefit Manager Support Center. Home to an array of public health programs, initiatives and interventions aimed at improving the health and well-being of women, infants, families and communities. A variety of reports & statistics for programs and services. Required if a repeating field is in error, to identify repeating field occurrence. Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately. If the original fills for these claims have no authorized refills a new RX number is required. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Generic Drug Not in Stock, 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. Note: the pharmacy may call the Pharmacy Support Center to request a zero co-pay if the medication is related to the treatment or prevention of COVID-19, or the treatment of a condition that may seriously complicate the treatment of COVID-19. See Appendix A and B for BIN/PCN. Prescription drugs and vaccines. Drugs administered in a dialysis unit are part of the dialysis fee or billed on a professional claim. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. Universal caseload, or task-based processing, is a different way of handling public assistance cases. Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. The claim may be a multi-line compound claim. There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. The Department does not pay for early refills when needed for a vacation supply. COVID-19 early refill overrides are not available for mail-order pharmacies. Plan Name PBM Name BIN PCN Group AETNA CVS Health 610591 ADV RX8834 AMERIGROUP Express Scripts 003858 MA WKLA AMERIHEALTH CARITAS LA PerformRx 600428 06030000 n/a . This link contains a list of Medicaid Health Plan BIN, PCN and Group Information. Information on the Children's Foster Care program and becoming a Foster Parent. The "Dispense as Written (DAW) Override Codes" table describes the valid scenarios allowable per DAW code. Watch the Oct. 12, 2022 Tailored Pan Roll Out Webinar here. Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. October 3, 2022 Stakeholder Meeting Presentation. Metric decimal quantity of medication that would be dispensed for a full quantity. Please refer to the specific rules and requirements regarding electronic and paper claims below. All electronic claims must be submitted through a pharmacy switch vendor. OptumRx Part-D and MAPD Plans BIN: 610097 PCN: 9999 Part-D WRAP Plans BIN: 610097 PCN: 8888 PCN: 8500 OptumRx (This represents former informedRx) BIN: 610593 PCN: HNEMEDD PHPMEDD PCN: SXCFLH . Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at, Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the. gcse.async = true; Medicare-Medicaid Coordination Private Insurance Innovation Center Regulations & Guidance Research, Statistics, Data & Systems Outreach & Education Back to HPMS Guidance History Clarification of Unique BIN (or BIN/PCN) Requirements as of January 1, 2012 Title Clarification of Unique BIN (or BIN/PCN) Requirements as of January 1, 2012 Date Required if necessary as component of Gross Amount Due. The chart below is the first page of the 2022 Medicare Part D pharmacy BIN and PCN list covering prescription drug plans from contracts E0654 through H1997. Louisiana Medicaid FFS & MCO BIN, PCN, and Group Numbers for pharmacy claims: . BIN: 610494. Required when there is payment from another source. Behavioral and Physical Health and Aging Services Administration Required if text is needed for clarification or detail. Claims that do not result in the Health First Colorado program authorizing reimbursement for services rendered may be resubmitted.

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