For non-mail order transactions, there is a maximum 20-day accumulation allowed every rolling 180 days. Information regarding methods to determine a Medicaid member's eligibility will be included in a subsequent Medicaid Update article. The public may submit comments on the drugs included or not included on the Common Formulary, new drug products, prior authorization criteria, step therapy criteria and other topics related to drug coverage under the Common Formulary. Required - If claim is for a compound prescription, enter "0. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. The Michigan Department of Health and Human Services' (MDHHS) Division of Environmental Health (DEH) uses the best available science to reduce, eliminate, or prevent harm from environmental, chemical, and physical hazards. 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. 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 . 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. Does not obligate you to see Health First Colorado members. If a member has Medicaid as their secondary insurance and their primary insurance covers a medication, but Health First Colorado requires a prior authorization for the medication, the pharmacy or provider may request a prior authorization override by contacting the Magellan Helpdesk at 1-800-424-5725. 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. 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. these fields were not required. Required if Patient Pay Amount (505-F5) includes co-pay as patient financial responsibility. The claim may be a multi-line compound claim. If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. 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. 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. 11 = Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN) area. The BIN is on the SPAP / ADAP table with a blank PCN and the BIN is unique to the SPAP / ADAP, or. The Bank Information Number (BIN) (Field 11A1) will change to "6184" for all claims. Information on the Family Independence Program, State Disability Assistance, SSI, Refugee, and other cash assistance. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. PCN Phone Fax Email HPMMCD (Medicaid) 866-984-6462 877-355-8070 info@meridianrx.com . Expanded Income and Title XIX (Fee-For-Service): Members with incomes up to 260% of the federal poverty level (expanded income) and in the Title XIX (Fee-For-Service) eligibility categories may receive up to a 12- month supply of contraceptives with a $0 co-pay. Electronic claim submissions must meet timely filing requirements. Leading zeroes in the NCPDP Processor BIN are significant. Pharmacies must keep records of all claim submissions, denials, and related documentation until final resolution of the claim. Please see the payer sheet grid below for more detailed requirements regarding each field. Required if Quantity of Previous Fill (531-FV) is used. Limitations, copayments, and restrictions may apply. In no case, shall prescriptions be kept in will-call status for more than 14 days. Representation by an attorney is usually required at administrative hearings. Pharmacy contact information is found on the back of all medical provider ID cards. 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. The Health First Colorado program restricts or excludes coverage for some drug categories. Required if other insurance information is available for coordination of benefits. On July 1, 2021, certain beneficiaries were enrolled in NC Medicaid Managed Care health plans, which will include the beneficiarys pharmacy benefits. Approval of a PAR does not guarantee payment. For non-scheduled drugs, 75 percent of the days' supply of the last fill must lapse before a drug can be filled again. Information on resources in your community and volunteer recruitment and training, and services provided at local DHS offices. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements. Access to medical specialists and mental health care. Required if needed to identify the transaction. 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. Use the following BIN/PCN when submitting claims to MORx: 004047/P021011511 Where should I send Medicare Part D excluded drug claims for participants? Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Maternal, Child and Reproductive Health billing manual web page. No blanks allowed. Author: jessica.jump Created Date: Enrolled Medicaid fee-for-service (FFS) members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies. Effective November 1, 2022, the Department is implementing a list of family planning-related drugs that may be covered pursuant to existing utilization management policies as outlined in the Appendix P, PDL or Appendix Y, if applicable. 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 . Member's 7-character Medical Assistance Program ID. All member ID numbers will be the same for the beneficiary whether they are enrolled in a health plan or in NC Medicaid Direct. Pharmacies can also check a member's enrollment with a West Virginia Medicaid MCO by calling 888-483-0793 The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. SCO Plan- Medicaid Only PBM BIN PCN Group Pharmacy Help Desk Commonwealth Care Alliance Navitus 610602 MCD MHO (877) 908-6023 Senior Whole Health CVS To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). If the reconsideration is denied, the final option is to appeal the reconsideration. 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 Primary Care ACOs PBM BIN PCN Group Pharmacy Help Desk Community Care Cooperative (C3) Conduent 009555 MASSPROD MassHealth (866) 246-8503 . Pursuant to 42CFR 455.10(b) and 42CFR 455.440, Health First Colorado will not pay for prescriptions written by unenrolled prescribers. Kentucky Medicaid Bin/PCN/Group Numbers effective Jan. 1, 2021 Additional Information Forms Medicaid Assistance Program (MAP) Forms MAC Price Research Request Form FFS PAD Billing PowerPoint Over-the-Counter (OTC) Drug Coverage Managed Care (MCO) Fee for Service (FFS) Provider Resources Billing Instructions Diabetic Supply Drug Information/List No. This page provides important information related to Part D program for Pharmaceutical companies. Required if needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Newsletter . Information on DHS Applications and Forms grouped by category. 24 hours a day/7 days a week or consult, When enrolling in a Medicare Advantage plan, you must continue to pay your. Required if Other Payer Reject Code (472-6E) is used. 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". Children's Special Health Care Services information and FAQ's. . Applicable co-pay is automatically deducted from the provider's payment during claims processing. IV equipment (for example, Venopaks dispensed without the IV solutions). If the medication is not on the family planning-related drug list, then the prescriber will need to complete a prior authorization to confirm that the drug was prescribed in relation to a family planning visit. 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. For all other information as it relates to family planning benefits, please visit the Maternal, Child and Reproductive Health billing manual web page. Required if Other Payer Amount Paid (431-Dv) is used. '//cse.google.com/cse.js?cx=' + cx; Pharmacies should continue to rebill until a final resolution has been reached. 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. Information on the Children's Foster Care program and becoming a Foster Parent. The Michigan Department of Health and Human Services (MDHHS) is soliciting comments from the public on the Michigan Medicaid Health Plan Common Formulary. 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. The PCN is defined by the PBM/processor as this identifier is unique to their business needs. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. Required if this field could result in contractually agreed upon payment. State of New York, Howard A. Zucker, M.D., J.D. The Step Therapy criteria for drugs indicated on the Medicaid Health Plan Common Formulary as requiring ST is below: Medicaid Common Formulary Workgroup Members. Any other pharmacy-related questions can be directed to the Medicaid Pharmacy Program at 1-800-437-9101. Pharmacy Help Desk Contact Information AmeriHealth Caritas: 866-885-1406 Carolina Complete Health: 833-992-2785 Healthy Blue: 833-434-1212 United Healthcare: 855-258-1593 WellCare: 866-799-5318, option 3 Prescribers may either switch members to a preferred product or may obtain a PA for a non-preferred product. Prescribers should review the Preferred Drug List (PDL), which contains a full listing of drugs/classes subject to the NYS Medicaid FFS Pharmacy Programs and additional information on clinical criteria prior to April 1, 2021. Required if Previous Date of Fill (530-FU) is used. A. Required if Other Payer ID (340-7C) is used. Required if Ingredient Cost Paid (506-F6) is greater than zero (0). below list the mandatory data fields. 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. October 3, 2022 Stakeholder Meeting Presentation, Stakeholder Meeting Questions and Answers, Frequently Asked Questions for Drug Manufacturers, Public Comment on MDHHS Medicaid Health Plan Common Formulary. Required if Patient Pay Amount (505-F5) includes amount exceeding periodic benefit maximum. Claims that cannot be submitted through the vendor must be submitted on paper. *Note: Code 09 is a negative amount and is not a valid option for field 351-NP. Field # NCPDP Field Name Value Req Comment 11-A1 BIN Number 004336, 610591 610084, 021007 020107, 020396 025052 M 'https:' : 'http:') + Pharmacies can submit these claims electronically or by paper. MassHealth PBM BIN PCN Group Primary Care Clinician (PCC) Plan Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer. Substitution Allowed - Pharmacist Selected Product Dispensed, 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. Sent when DUR intervention is encountered during claim processing. Please contact individual health plans to verify their most current BIN, PCN and Group Information. The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. Mail: Medi-Cal Rx Customer Service Center, Attn: PA Request, PO Box 730, Sacramento, CA 95741-0730. Our. Non-maintenance products submitted by a pharmacy for mail-order prescriptions will deny. |Fax Number: 517-763-0142, E-mail Address: MDHHSCommonFormulary@michigan.gov, Adult & Children's Services collapsed link, Safety & Injury Prevention collapsed link, Emergency Relief: Home, Utilities & Burial, Adult Behavioral Health & Developmental Disability, https://dev.michigan.local/som/json?sc_device=json, Pre-Single PDL Changes (before October 1, 2020). 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. 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. 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