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. 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 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. . In order to participate in the Discount . Payer Name: Iowa Medicaid Enterprise Date: August 14, 22 Plan Name/Group Name: Iowa Medicaid BIN:11933 PCN:IAPOP Processor: IME POS Unit (CHC) Effective as of September 21, 22 NCPDP Telecommunication Standard Version/Release #: D. NCPDP Data Dictionary Version Date: July 27 NCPDP External Code List Version Date: April 218 You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Member's 7-character Medical Assistance Program ID. Ohio Medicaid Managed Care Plan Pharmacy Benefit Administrator, BIN, PCN, and Group Specialty Pharmacy name and telephone number Website address for pharmacy information Aetna Better Health CVS/ Caremark 1-855-364-2975 Medicare/Medicaid Members BIN: 610591 PCN: MEDDADV Group: RX8812 Medicaid Only Members BIN: 610591 PCN: ADV Group: RX 8810 The resubmitted request must be completed in the same manner as an original reconsideration request. Please contact the plan for further details. Required if this field could result in contractually agreed upon payment. All member ID numbers will be the same for the beneficiary whether they are enrolled in a health plan or in NC Medicaid Direct. 13 = Amount Attributed to Processor Fee (571-NZ). The PCF should be submitted to Magellan Rx Management agent at: Below are the completion instructions for the Colorado Pharmacy Claim Form (PCF-2) for Pharmacy Providers. The following NCPDP fields below will be required on 340B transactions. The comments will be reviewed by MDHHS and the Michigan Medicaid Health Plan Common Formulary Workgroup. Leading zeroes in the NCPDP Processor BIN are significant. NOTE: This prior authorization override request with the Helpdesk only applies when claim records indicate that primary insurance was successfully billed first and if the medication is a covered pharmacy benefit. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements. Our. Recursively sort the rest of the list, then insert the one left-over item where it belongs in the list, like adding a . All Medicaid members are assigned a CIN even if they are enrolled in a Medicaid managed care (MMC) plan. 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. Effective April 1, 2021, the following Medicaid Pharmacy FFS Programs will also apply to Medicaid managed care members: Please refer to the October 2020 Medicaid Update article titled Attention: Pharmacies Durable Medical Equipment, Prosthetics, Orthotics, and Supply Providers, and Prescribers That are Not Enrolled in Medicaid Fee-for-Service. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. These are all of the BIN/PCN/Group ID numbers that will be accepted by ACS: Former Codes New Codes Who BIN PCN from Pharmacy NCPDP Group ID from Pharmacy BIN PCN from Pharmacy NCPDP Group ID from Pharmacy BCCDT 010454 P012010454 MDBCCDT 610084 DRDTPROD MDBCCDT Required if this field is reporting a contractually agreed upon payment. Equal Opportunity, Legal Base, Laws and Reporting Welfare Fraud information. Use the following BIN/PCN when submitting claims to MORx: 004047/P021011511 Where should I send Medicare Part D excluded drug claims for participants? Please visit the OPR section of the Department's website for more detailed information about enrollment and compliance with the Affordable Care Act. Medicaid pharmacy policy and operations questions should be directed to (518)4863209. This page provides important information related to Part D program for Pharmaceutical companies. OTHER PAYER - PATIENT RESPONSIBILITY AMOUNT COUNT, Required if Other Payer-Patient Responsibility Amount Qualifier (351-NP) is used, OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFER, Required if Other Payer-Patient Responsibility Amount (352-NQ) is used352-NQ. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Child Welfare Medical and Behavioral Health Resources. Instructions on how to complete the PCF are available in this manual. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. 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)). Sent when claim adjudication outcome requires subsequent PA number for payment. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. Copies of all forms necessary for submitting claims are also available on the Pharmacy Resources web page of the Department's website. BIN - 800008 PCN - not required Group - not required > SelectHealth Advantage (Medicare Part D) BIN - 015938 PCN - 7463 Group - UT/ID = U1000009; NV Intermountain = U1000011 > SelectHealth Community Care (Utah State Medicaid) BIN - 800008 PCN - 606 Group - not required Scroll down for health plan specific information. Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. For MMAI plans, fax 800-693-6703, call 1-877-723-7702 (TTY/TDD 711) or submit electronically on . Cost-sharing for members must not exceed 5% of their monthly household income. Incremental and subsequent fills may not be transferred from one pharmacy to another. Supplies listed in the Pharmacy Procedures and Supply Codes, such as enteral and parenteral nutrition, family planning and medical/surgical supplies are subject to the Pharmacy Carve-Out. Required if Approved Message Code (548-6F) is used. For non-mail order transactions, there is a maximum 20-day accumulation allowed every rolling 180 days. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. Providers should also consult the Code of Colorado Regulations (10 C.C.R. Required when needed to communicate DUR information. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. Required on all COB claims with Other Coverage Code of 2 or 4 - Required if Other Payer Amount Paid Qualifier (342-HC) is used. Required when additional text is needed for clarification or detail. Required only for secondary, tertiary, etc., claims. Pharmacies that are not enrolled in the FFS program as billing providers must enroll, in order to continue to serve Medicaid Managed Care members. Michigan's Women, Infants & Children program, providing supplemental nutrition, breastfeeding information, and other resources for healthy mothers & babies. This value is the prescription number from the first partial fill. Required if Other Payer ID (340-7C) is used. See below for instructions on requesting a PA or refer to the PDP web page. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. Instructions for checking enrollment status, and enrollment tips can be found in this article. No blanks allowed. 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). Information on treatment and services for juvenile offenders, success stories, and more. Your pharmacy coverage is included in your medical coverage. Required if utilization conflict is detected. 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 use of inaccurate or false information can result in the reversal of claims. Required on all COB claims with Other Coverage Code of 2. Limitations, copayments, and restrictions may apply. below list the mandatory data fields. Required for partial fills. What is the Missouri Rx Plan (MORx) BIN/PCN? Effective April 1, 2021, Medicaid members enrolled in mainstream Managed Care (MC) plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plan (SNPs) will receive their pharmacy benefits through the Medicaid FFS Pharmacy Program instead of through their Medicaid MC plan as they do now. "P" indicates the quantity dispensed is a partial fill. More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. New York Managed Medicaid Plans processed by Caremark will cover COVID-19 specimen collection or CLIA waived COVID-19 testing at pharmacies in accordance with the New York Governor's Executive Order #202.24. 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". 'https:' : 'http:') + Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. The Helpdesk is available 24 hours a day, seven days a week. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). Information about injury and violence prevention programs in Michigan. 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. Completed PA forms should be sent to (800)2682990 . MedImpact is the prescription drug provider for all medical Plans. BIN 610591 20107 610649 4336 4336 610494 11529 PCN ADV KY 3191501 MCAIDADV MCAIDADV 4040 P022011529 GROUP RX8831 WKVA RX5035 RX8893 ACUKY KY Medicaid PBM CVS Caremark IngenioRx Humana Pharmacy Solutions CVS Caremark CVS Caremark Optum Rx Magellan Kentucky Medicaid Bin/PCN/Group Numbers Effective 1/1/2021. Current beneficiaries can find out which health plan theyareenrolled in bycalling the Beneficiary Help Line at 800-642-3195 (TTY 866-501-5656) or bylogging in to theirmyHealth Portal account online atwww.michigan.gov/myhealthportal. Pharmacies may electronically rebill denied claims when the claim submission is within 120 days of the date of service. Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim. Required if Other Amount Claimed Submitted (480-H9) is greater than zero (0). Restricted products by participating companies are covered as follows: The following are not benefits of the Health First Colorado program: The following are not pharmacy benefits of the Health First Colorado program: The pharmacy benefit manager provides a Pharmacy Support Center to handle clinical, technical, and member calls. It is used for multi-ingredient prescriptions, when each ingredient is reported. Effective 10/22/2021, Corrected formatting error; replaced "" with numeric "0", Added Real Time Prior Authorization via EHR to PAR Process, Updated to reflect billing changes to family planning and family planning-related services, Updated family planning-related section for clarity, Added primary insurance clarification to PAR Process and max day supply clarification to Dispensing Requirements, Added record maintenance requirements under Counseling, Retention of Records, and Signature Requirements, Removed requirement for providers to obtain a new override each fill for TPL/COB prior authorizations, Updated qualifier codes accepted in COB/ Other Payments under Claim Billing, Proposed rendering provider (if identified on the PAR), 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, 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. See Appendix A and B for BIN/PCN combinations and usage. Providers must follow the instructions below and may only submit one (prescription) per claim. Basis of Cost Determination = This is not a required field on the claim, but 05 (Acquisition) or 08 (340B/Disproportionate Share Pricing/Public Health Service) will be accepted if submitted on the claim. For more information related to physician administered drugs and billing for this population, please visit the Physician-Administered-Drug (PAD) Billing Manual. The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. the Medicaid card. 1-5 = Refill number - Number of the replenishment, 8 = Substitution Allowed-Generic Drug Not Available in Marketplace, 1-99 = Authorized Refill number - with 99 being as needed, refills unlimited, 8 = Process Compound For Approved Ingredients. Required if a repeating field is in error, to identify repeating field occurrence. gcse.type = 'text/javascript'; To find out if a medication is a covered pharmacy benefit, refer to the Appendix P and/or the Preferred Drug List (PDL) located on the Pharmacy Resources web page. Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. If the reconsideration is denied, the final option is to appeal the reconsideration. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. The shaded area shows the new codes. Please refer to the specific rules and requirements regarding electronic and paper claims below. 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. For non-scheduled drugs, 75 percent of the days' supply of the last fill must lapse before a drug can be filled again. The MC plans will share with the Department the PAs that have been previously approved. The Processor Control Numbers (PCN) (Field 14A4) will change to: o "DRTXPROD" for Medicaid, CHIP, and CSHCN claims. 01 = Amount Applied to Periodic Deductible (517-FH), 02 = Amount Attributed to ProductSelection/Brand Drug (134-UK), 03 = Amount Attributed to Sales Tax(523-FN), 04 = Amount Exceeding Periodic Benefit Maximum (520-FK), 06 = Patient Pay Amount (Deductible) (505-F5), 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection(135-UM), 10 = Amount Attributed to Provider Network Selection (133-UJ), 11 = Amount Attributed to Product Selection/Brand Non-Preferred FormularySelection(136-UN), 12 = Amount Attributed to Coverage Gap (137-UP), 13 = Amount Attributed to Processor Fee (571-NZ), MA = Medication Administration - use for vaccine. MassHealth PBM BIN PCN Group Primary Care Clinician (PCC) Plan 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. 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)]. Changes may be made to the Common Formulary based on comments received. 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. Bridge Card Participation Information on Electronic Benefits for clients and businesses, lists of participating retailers and ATMs, and QUEST. Maternal, Child and Reproductive Health billing manual web page. The Field is mandatory for the Segment in the designated Transaction. Please call a Health Program Representative (HPR) at 1-866-608-9422 with Medicaid benefit questions. Member Contact Center1-800-221-3943/State Relay: 711. MCOs* PBM BIN PCN Group BMC HealthNet Health Plan Envision 610342 BCAID MAHLTH Tufts Health Together Caremark 004336 ADV RX1143 *Members of the Lahey Clinical Performance Network ACO should submit claims to the appropriate MCO using the information above. The individual managed care entities (MCEs) serving Healthy Indiana Plan (HIP), Hoosier Care Connect and Hoosier Healthwise members contract with designated pharmacy benefit managers (PBMs) to manage the pharmacy benefits and process pharmacy claims for their enrolled members under the IHCP managed care delivery system. 10 = Amount Attributed to Provider Network Selection (133-UJ) Notification of PAR approval or denial is sent to each of the following parties: In addition to stating whether the PAR has been approved or denied, a PAR denial notification letter is sent to members. Members previously enrolled in PCN were automatically enrolled in Medicaid. These source documents, in addition to any work papers and records used to create electronic media claims, shall be retained by the provider for seven years and shall be made readily available and produced upon request of the Secretary of the Department of Health and Human Services, the Department, and the Medicaid Fraud Control Unit and their authorized agents. CMS included the following disclaimer in regards to this data: 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. Required if identification of the Other Payer Date is necessary for claim/encounter adjudication. Pursuant to 42CFR 455.10(b) and 42CFR 455.440, Health First Colorado will not pay for prescriptions written by unenrolled prescribers. 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