State of Idaho Medicaid Pharmacy Claims Submission Manual Version 1.13 March 13, 2014
State of Idaho Medicaid Pharmacy Claims Submission Manual Version 1.13 March 13, 2014 Proprietary & Confidential © 2014, Magellan Health Services, Inc. All Rights Reserved. State of Idaho Medicaid Pharmacy Claims Submission Manual Revision History Document Version Date Name Comments 1.0 12/23/09 Training and Development Department Initial creation of document 1.2 01/28/10 Training and Development Revision to Hospice information, lock in information and payment algorithms 1.4 03/25/10 Training and Development; Documentation Mgmt. Team 1.5 05/27/10 Documentation Mgmt. Team Added information about 340b Providers, added DME PA phone number, and revised paper claims mailing address 1.7 05/31/11 Training and Development; Documentation Mgmt. Team 1.1 1.3 1.6 1.8 1.9 1.10 1.11 1.12 1.13 Page 2 01/05/10 Training and Development Department Revision to Unisys phone number and Magellan Medicaid Administration URL 01/29/10 Training and Development 06/04/10 Training and Development 06/09/11 Training and Development 10/03/11 Wil Gallardo 07/26/12 Training and Development; Documentation Mgmt. Team 01/08/13 Documentation Mgmt. Team 11/21/13 Mandy Kight 03/13/14 Michelle Williams Revision to payment algorithms, dispense fees, removed submission clarification codes and changed Provider relations phone number Updated company name New screen print for updated company name Added Section 7.3.3 PERM Revision to Section 7.3.3 PERM Updated sections 7.3.1 and 7.3.2 Updated to new format and modified for D.0 Rebranded Removed reference to hospice claims from the Clinical Segment table in Section 4.2.3. Updated Section 7.6.2, Diagnosis Codes – Hospice Recipients. Updated Sections 7.3.1 and 7.3.1.3 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Confidential and Proprietary Page 3 State of Idaho Medicaid Pharmacy Claims Submission Manual Table of Contents Revision History .................................................................................................................................2 Table of Contents ...............................................................................................................................4 1.0 Introduction ..........................................................................................................................6 1.1 Idaho Department of Health and Welfare (IDHW) Pharmacy Program ...................................... 6 1.2 Pharmacy Benefit Manager (PBM) – Magellan Medicaid Administration .................................. 6 2.0 Billing Overview .....................................................................................................................8 2.1 Enrolling as an IDHW-Approved Pharmacy ................................................................................. 8 2.2 Claim Formats and IDHW – Specific Values................................................................................. 8 2.3 Magellan Medicaid Administration’s Website for Idaho............................................................. 8 2.4 Important Contact Information ................................................................................................... 9 3.0 Magellan Medicaid Administration’s Call Center ...................................................................10 3.1 Pharmacy Support Center ......................................................................................................... 10 3.2 Web Support Call Center ........................................................................................................... 11 4.0 Program Setup .....................................................................................................................12 4.1 Claim Format ............................................................................................................................. 12 4.2 Point-of-Sale – NCPDP Version D.0............................................................................................ 12 4.2.1 Supported POS Transaction Types ........................................................................................ 13 4.2.2 Required Data Elements........................................................................................................ 14 4.2.3 POS Changes.......................................................................................................................... 16 4.3 Paper Claim – Universal Claim Form ......................................................................................... 17 4.4 Web Claims Submission............................................................................................................. 18 5.0 Service Support....................................................................................................................20 5.1 Online Certification.................................................................................................................... 20 5.2 Solving Technical Problems ....................................................................................................... 20 6.0 Online Claims Processing Edits .............................................................................................22 6.1 Paid, Denied, and Rejected Responses...................................................................................... 22 6.2 Duplicate Response ................................................................................................................... 22 7.0 Program Specifications .........................................................................................................24 7.1 Timely Filing Limits .................................................................................................................... 24 7.1.1 Date Rx Written to Date of Service Edits .............................................................................. 24 7.2 Dispensing Limits/Claim Restrictions......................................................................................... 25 7.2.1 Days’ Supply .......................................................................................................................... 25 7.2.2 Quantity................................................................................................................................. 25 7.2.3 Minimum/Maximum Age Limits ........................................................................................... 25 7.2.4 Refills ..................................................................................................................................... 25 7.3 Provider Reimbursement .......................................................................................................... 26 7.3.1 Provider Reimbursement Rates ............................................................................................ 26 7.3.2 Provider Dispensing Fees ...................................................................................................... 27 Page 4 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual 7.3.3 Payment Error Rate Measurement (PERM) .......................................................................... 27 7.4 Client Co-Pays ............................................................................................................................ 28 7.5 Prior Authorizations................................................................................................................... 28 7.6 Special Participant Conditions ................................................................................................... 29 7.6.1 Lock-In ................................................................................................................................... 29 7.6.2 Diagnosis Codes/Hospice Recipients..................................................................................... 30 7.7 Compound Claims...................................................................................................................... 30 7.7.1 Fields Required for Submitting Multi-Ingredient Compounds .............................................. 31 8.0 Coordination of Benefits (COB) .............................................................................................32 8.1 COB General Instructions .......................................................................................................... 32 8.1.1 COB Process........................................................................................................................... 32 9.0 Appendix A – Idaho D.0 Payer Specification ..........................................................................36 10.0 Appendix B – Universal Claim Form Sample ..........................................................................38 11.0 Appendix C – ProDUR ...........................................................................................................40 11.1 ProDUR Problem Types ............................................................................................................. 40 11.2 Drug Utilization Review (DUR) Fields ........................................................................................ 42 12.0 Appendix D – ProDUR and POS Reject Codes Messages .........................................................44 12.1 ProDUR Alerts ............................................................................................................................ 44 12.2 Point-of-Sale Reject Codes and Messages................................................................................. 45 13.0 Appendix E – Directory/Addresses........................................................................................56 14.0 Index ...................................................................................................................................58 Confidential and Proprietary Page 5 State of Idaho Medicaid Pharmacy Claims Submission Manual 1.0 Introduction 1.1 Idaho Department of Health and Welfare (IDHW) Pharmacy Program This manual provides claims submission guidelines for the Medicaid pharmacy program administered by IDHW. Important IDHW coverage and reimbursement policies are available in this State of Idaho Medicaid Pharmacy Claims Submission Manual. The Magellan Medicaid Administration website for IDHW contains a link to this document. Subsequent revisions to this document are available by accessing the link. • 1.2 For the most current version of this manual, refer to the Magellan Medicaid Administration website at https://idaho.fhsc.com. Pharmacy Benefit Manager (PBM) – Magellan Medicaid Administration IDHW contracts with Magellan Medicaid Administration as its pharmacy benefit manager (PBM) to Adjudicate claims; Provide Pharmacy Support Center services for providers; Perform prospective drug utilization review (ProDUR) and retrospective drug utilization review (RetroDUR); and Process member calls. IDHW continues to process clinical prior authorizations (PA). Page 6 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Confidential and Proprietary Page 7 State of Idaho Medicaid Pharmacy Claims Submission Manual 2.0 Billing Overview 2.1 Enrolling as an IDHW-Approved Pharmacy The Idaho Medicaid Pharmacy Provider Network consists of IDHW-contracted pharmacies. To enroll as a Medicaid pharmacy provider, please use the following steps: Existing providers need to update their records utilizing Provider Record Update (PRU) (Molina’s online system). 208-373-1424 866-686-4272 Fax: 877-517-2041 Hours are Monday–Friday, 8:00 a.m.–5:00 p.m., MT New providers enrolled with HP (formally known as EDS) at 800-685-3757 until January 15, 2010. Beginning on January 18, 2010, new pharmacies began enrolling through the Molina web portal: www.idmedicaid.com. Contact Molina by telephone at 866-686-4272 or by e-mail at [email protected]. All billing providers must have an active National Provider Identifier (NPI). Providers must submit the NPI in the Service Provider ID field (NCPDP Field # 2Ø1-B1). 2.2 Claim Formats and IDHW – Specific Values Pharmacy claims may be submitted online by point-of-sale (POS), web claims submission, or paper using the following National Council for Prescription Drug Programs (NCPDP) standards: POS: NCPDP Version D.0 Batch: NCPDP Batch 1.1 (contact Magellan Medicaid Administration at 1-804-965-7400 and ask for Plan Admin) Paper: Universal Claim Form (PUCF_D02PT for Standard Version D.0) Web Claims: NCPDP Version D.0 2.3 Refer to Section 4.1 – Claim Format for further details on acceptable claim formats and specifications. Magellan Medicaid Administration’s Website for Idaho Announcements, provider forms, drug information, provider manuals, Medicaid policies, and bulletins are posted on the Magellan Medicaid Administration website at https://idaho.fhsc.com. Page 8 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual This website went live on January 4, 2010. 2.4 Important Contact Information Refer to Section 13.0 – Appendix E – Directory/Addresses at the end of this manual for important phone numbers, mailing addresses, and websites. Confidential and Proprietary Page 9 State of Idaho Medicaid Pharmacy Claims Submission Manual 3.0 Magellan Medicaid Administration’s Call Center Magellan Medicaid Administration has both a Pharmacy Support Center and Web Support Call Center to assist pharmacies, prescribers, and members. Section 13.0 – Appendix E – Directory/Addresses at the end of this manual lists their phone numbers along with their hours of operation. 3.1 Pharmacy Support Center 800-922-3987 (Nationwide Toll-Free Number) Magellan Medicaid Administration provides a toll-free number for pharmacies available 7 days a week, 24 hours a day, and 365 days a year. The Pharmacy Support Center responds to questions on coverage, claims processing, and client eligibility. Examples of issues addressed by the Pharmacy Support Center staff include, but are not limited to, the following: Questions on Claims Processing Messages – If a pharmacy needs assistance with alert or denial messages, it is important to contact the Pharmacy Support Center at the time of dispensing drugs. Magellan Medicaid Administration’s staff is able to provide claim information on all error messages, including messaging from the ProDUR system. Clinical Issues – The Pharmacy Support Center is not intended to be used as a clinical consulting service and cannot replace or supplement the professional judgment of the dispensing pharmacist. However, a second level of assistance is available if a pharmacist’s question requires a clinical response. To address these situations, IDHW has a Pharmacy Call Center that will provide assistance with initiating clinical prior authorizations. The call center hours are Monday–Friday, 8:00 a.m.–5:00 p.m., MT. Effective January 22, 2010, the IDHW call center is closed every other Friday at 12:00 p.m., MT. This schedule was in effect until June 2010. Page 10 208-364-1829 866-827-9967 Fax: 800-327-5541 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual 3.2 Web Support Call Center 800-241-8726 (Nationwide Toll-Free Number) Magellan Medicaid Administration provides a toll-free number for providers. This toll-free line is staffed Monday–Friday, 6:00 a.m.–6:00 p.m., MT. The Web Support Call Center responds to questions on accessing the various web applications, password management, navigation, and general questions. Examples of issues addressed by the Web Support Call Center staff include, but are not limited to, the following: Questions on changing passwords in User Administration Console (UAC) – If providers need assistance with changing their passwords or are if they are getting an alert that their password is locked out. Questions on navigating the various web applications – If providers need assistance in navigating through various web applications, the Web Support Call Center can assist by explaining how to access the applications, log in, and maneuver the systems. Confidential and Proprietary Page 11 State of Idaho Medicaid Pharmacy Claims Submission Manual 4.0 Program Setup 4.1 Claim Format While Magellan Medicaid Administration strongly recommends claims submission by POS, paper claims and web claims submission are also allowed. Additionally, paper claims submission is required for timely filing overrides when the new claim exceeds the filing limits. The following standard formats are accepted. Each is explained in subsequent sections. Table 4.1.1 – Claim Formats Accepted by Magellan Medicaid Administration Billing Media NCPDP Version POS Version D.0 Web Claims Submission NCPDP D.0 Paper Claim Batch 4.2 Universal Claim Form (D.0 UCF) NCPDP Batch 1.1 Point-of-Sale – NCPDP Version D.0 Comments Online POS and web claims submission is preferred. PUCF_D02PT for Standard Version D.0 Contact Magellan Medicaid Administration with questions in regards to processing batch claims. As part of claims processing, Magellan Medicaid Administration uses an online POS system to provide submitters with real-time online information regarding Client eligibility; Drug coverage; Dispensing limits; Pricing; Payment information; and ProDUR. The POS system is used in conjunction with a pharmacy’s in-house operating system. While there are a variety of different pharmacy operating systems, the information contained in this manual specifies only the response messages related to the interactions with the Magellan Medicaid Administration online system and not the technical operation of a pharmacy’s in-house-specific system. Pharmacies should check with their software vendors to ensure their system is able to process as per the payer specifications listed in Section 9.0 – Appendix A – Payer Specifications of this manual. Page 12 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual 4.2.1 Supported POS Transaction Types Magellan Medicaid Administration has implemented the following NCPDP Version D.0 transaction types. A pharmacy’s ability to use these transaction types depends on its software. At a minimum, pharmacies should have the capability to submit original claims (B1), reversals (B2), and re-bills (B3). Other transactions listed in Table 4.2.1.1 – NCPDP Version D.0 Transaction Types Supported are also supported. Original Claims Adjudication (B1) – This transaction captures and processes the claim and returns the dollar amount allowed under the program’s reimbursement formula. The B1 transaction will be the prevalent transaction used by pharmacies. Claims Reversal (B2) – This transaction is used by a pharmacy to cancel a claim that was previously processed. To submit a reversal, a pharmacy must void a claim that has received a PAID status and select the REVERSAL (Void) option in its computer system. Claims Re-Bill (B3) – This transaction is used by the pharmacy to adjust and resubmit a claim that has received a PAID status. A “claim re-bill” voids the original claim and resubmits the claim within a single transaction. The B3 claim is identical in format to the B1 claim with the only difference being that the transaction code (Field # 1Ø3) is equal to B3. The following fields must match the original paid claim for a successful transmission of a B2 (Reversal) or B3 (Re-bill): Service Provider ID – NPI Number Prescription Number Date of Service (Date Filled) Table 4.2.1.1 – NCPDP Version 5.1 Transaction Types Supported NCPDP D.0 Transaction Code Transaction Name B1 Billing B3 Re-bill B2 E1 P1 P2 P3 P4 N1 N2 N3 C1 Reversal Eligibility Inquiry Prior Authorization Request and Billing Prior Authorization Reversal Prior Authorization Inquiry Prior Authorization Request Only Information Reporting Information Reporting Reversal Information Re-bill Controlled Substance Reporting Confidential and Proprietary Page 13 State of Idaho Medicaid Pharmacy Claims Submission Manual NCPDP D.0 Transaction Code C2 Transaction Name Controlled Substance Reporting Reversal C3 4.2.2 Controlled Substance Reporting Re-bill Required Data Elements A software vendor needs Magellan Medicaid Administration’s payer specifications to set up a pharmacy’s computer system to allow access to the required fields and to process claims. The Magellan Medicaid Administration Claims Processing system has program-specific field requirements; e.g., Mandatory, Situational, and Not Required. Table 4.2.2.1 – Definitions of Field Requirements Indicators Used in Payer Specifications lists abbreviations that are used throughout the payer specifications to depict field requirements. Table 4.2.2.1 – Definitions of Field Requirements Indicators Used In Payer Specifications Code M Description MANDATORY Designated as MANDATORY in accordance with the NCPDP Telecommunication Implementation Guide Version D.0. The fields must be sent if the segment is required for the transaction. R REQUIRED Fields with this designation according to this program’s specifications must be sent if the segment is required for the transaction. RW QUALIFIED REQUIREMENT “Required when” the situations designated have qualifications for usage (“Required if x,” “Not required if y”). Claims are not processed without all of the required (or mandatory) data elements. Required (or mandatory) fields may or may not be used in the adjudication process. Also, fields not required at this time may be required at a future date. Claims are edited for valid format and valid values on fields that are not required. If data are submitted in fields not required for processing as indicated by the payer specifications, the data are subjected to valid format/valid value checks. Failure to pass those checks result in claim denials. Required Segments – The transaction types implemented by Magellan Medicaid Administration have NCPDP-defined request formats or segments. Table 4.2.2.2 – Segments Supported for B1, B2, and B3 Transaction Types lists NCPDP segments used. Page 14 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Table 4.2.2.2 – Segments Supported for B1, B2, and B3 Transaction Types Transaction Type Codes Segment B1 B2 B3 Header M M M Insurance M S M Pharmacy Provider S N S Patient S Claim S S M M Prescriber M S M Worker’s Comp S N S COB/Other Payments DUR/PPS S N S S Pricing M Compound S Coupon Prior Authorizations Clinical Facility M = Mandatory S = Situational S M N S N S N S S S S S M S S N S N N = Not Used S Payer Specifications – A list of transaction types and their field requirements is available in Section 9.0 – Appendix A – Payer Specifications. These specifications list B1, B2, and B3 transaction types with their segments, fields, field requirement indicators (mandatory, situational, optional), and values supported by Magellan Medicaid Administration. Program Setup – Table 4.2.2.3 – Important Required Values for Program Set Up lists required values unique to Idaho programs. Table 4.2.2.3 – Important Required Values for Program Set Up Fields Description BIN# 014864 Group IDMEDICAID Processor Control # Provider ID # Cardholder ID # Confidential and Proprietary Comments P043014864 NPI 10 bytes (numeric) Idaho Medicaid ID number 10 bytes (numeric) Note: If provider is 100 percent paper-based, will submit atypical/Medicaid number. Page 15 State of Idaho Medicaid Pharmacy Claims Submission Manual Fields Description Prescriber ID # NPI state license number Product Code National Drug Code (NDC) 4.2.3 POS Changes Comments 10 bytes (numeric) Length and format may vary. State license number should be submitted only when the NPI is not accessible or available. 11 digits There have been changes in claims processing from the previous vendor. Table 4.2.3.1 – POS Changes lists these changes along with the NCPDP segments and field numbers. Table 4.2.3.1 – POS Changes Transaction Header Segment Field Number Values BIN Number 1Ø1-A1 014864 Software Vendor/Certification ID 11Ø-AK TBD Processor Control Number Patient Segment Pregnancy Indicator Insurance Segment 1Ø4-A4 P043014864 Field Number 335-2C Field Number Values IDMEDICAID Number of Refills 415-DF 0-99 Prescription Origin Code Page 16 419-DJ Comment Blank = Not Specified 1 = Not Pregnant 2 = Pregnant 3Ø1-C1 Field Number Assigned when vendor is certified with Magellan Medicaid Administration. Billings will reject if missing or not valid Values Group ID Claim Segment Comment Values Comment Comment 0 = Not specified 1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile 5 = Pharmacy Enter number of refills authorized. Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual COB Segment Field Number Other Payer Reject Count 471-5E Other Payer Reject Code 472-6E Other Payer-Patient Responsibility Amount 352-NQ Values Comment Required when submitting Other Coverage Code = 3 Required when submitting Other Coverage Code = 3 Required when submitting Other Coverage Code = 2 or 4. Rejected if Not submitted with Other Coverage Code = 2 or 4 OR Clinical Segment Field Number Diagnosis Code Count 491-VE Diagnosis Code Qualifier 492-WE Diagnosis Code 424-DO 4.3 Values Paper Claim – Universal Claim Form Submitted on claims where Other Coverage Code is NOT equal to 2 or 4. Comment Required when submitting diagnosis information. Required when submitting diagnosis information. Required when submitting diagnosis information. All paper pharmacy claims must be submitted to Magellan Medicaid Administration on a Universal Claim Form (UCF, version PUCF_D02PT). Section 13.0 – Appendix E – Directory/Addresses at the end of this manual specifies An alternative source for obtaining UCFs; and The Magellan Medicaid Administration address that pharmacies must use when sending completed UCF billings. Confidential and Proprietary Page 17 State of Idaho Medicaid Pharmacy Claims Submission Manual Completion instructions for the UCF are listed in Section 10.0 – Appendix B – Universal Claim Form Sample, Version D.0 For certain billings outside the norm, Magellan Medicaid Administration may require or accept UCF submissions. Claims that require a UCF are 4.4 Claims submitted that exceed the timely filing limits. The UCF must provide documentation of the Internal Control Number (ICN) of the original denied claim to allow payment for the current claim. Web Claims Submission Refer to the Web Claims Submission User Guide for more information. This guide is available at https://idaho.fhsc.com. Page 18 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Confidential and Proprietary Page 19 State of Idaho Medicaid Pharmacy Claims Submission Manual 5.0 Service Support 5.1 Online Certification The Software Vendor/Certification Number (NCPDP Field # 11Ø-AK) of the Transaction Header Segment is required for claims submission under NCPDP Version D.0; providers should submit the value that is assigned to them when being certified. Magellan Medicaid Administration certifies software vendors, not an individual pharmacy’s computer system. A pharmacy should contact its vendor or Magellan Medicaid Administration to determine if the required certification has been obtained. For assistance with software vendor certification, contact Magellan Medicaid Administration. Refer to Section 13.0 – Appendix E – Directory/Addresses at the end of this manual for other contact information. 5.2 Solving Technical Problems Pharmacies receive one of the following messages when the Magellan Medicaid Administration POS system is unavailable: Table 5.2.1 – Host System Problem Messages and Explanations NCPDP Message Explanation 90 Host Hung Up Host disconnected before session completed. 93 Planned Unavailable Transmission occurred during scheduled downtime. Scheduled downtime for file maintenance is Saturday, 9:00 p.m., MT–Sunday, 4:00 a.m., MT. 92 99 System Unavailable/Host Unavailable Host Processing Error Processing host did not accept transaction or did not respond within time out period. Do not retransmit claims. Magellan Medicaid Administration strongly recommends that a pharmacy’s software has the capability to submit backdated claims. Occasionally, a pharmacy may also receive messages that indicate its own network is having problems communicating with Magellan Medicaid Administration. If this occurs, or if a pharmacy is experiencing technical difficulties connecting with the Magellan Medicaid Administration system, pharmacies should follow the steps outlined below: 1. Check the terminal and communication equipment to ensure that electrical power and telephone services are operational. 2. Call the telephone number that the modem is dialing and note the information heard (i.e., fast busy, steady busy, recorded message). 3. Contact the software vendor if unable to access this information in the system. Page 20 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual 4. If the pharmacy has an internal technical staff, forward the problem to that department, then the internal technical staff should contact Magellan Medicaid Administration to resolve the problem. 5. If unable to resolve the problem after following the steps outlined above, directly contact the Magellan Medicaid Administration Pharmacy Support Center. Refer to Section 13.0 – Appendix E – Directory/Addresses at the end of this manual for contact information. Confidential and Proprietary Page 21 State of Idaho Medicaid Pharmacy Claims Submission Manual 6.0 Online Claims Processing Edits 6.1 Paid, Denied, and Rejected Responses After an online claims submission is made by a pharmacy, the POS system returns a message to indicate the outcome of the processing. If the claim passes all edits, a PAID message is returned with the allowed reimbursement amount. A claim that fails an edit and is REJECTED (or DENIED) also returns with an NCPDP rejection code and message. Refer to Section 12.0 – Appendix D – POS Reject Codes and Messages for a list of POS rejection codes and messages. 6.2 Duplicate Response A duplicate disposition occurs when there is an attempt to submit a claim that has already gone through the adjudication process with either some or all of the previous claims information. An exact match on the following fields results in a duplicate disposition: Same Patient/Client Same Service Provider ID Same Date of Service Same Product/Service ID Same Prescription/Service Reference Number Fill Number In situations where there are matches on some of the above data elements, Magellan Medicaid Administration returns an NCPDP Error Code # 83 – Duplicate Paid Claim to indicate a possible suspected duplicate. There are situations where the provider sends the transaction request and Magellan Medicaid Administration receives the request and processes the transaction. Then, due to communication problems or interruptions, the response is not received by the provider. In these cases, the provider should resubmit the transaction request. Magellan Medicaid Administration responds with the same information as the first response, but the transaction response is marked as duplicate. Page 22 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Confidential and Proprietary Page 23 State of Idaho Medicaid Pharmacy Claims Submission Manual 7.0 Program Specifications 7.1 Timely Filing Limits Most pharmacies that utilize the POS system submit their claims at the time of dispensing the drugs. However, there may be mitigating reasons that require a claim to be submitted retroactively. For all original claims and adjustments, the timely filing limit is 366 days from the date of service (DOS). For reversals, the filing limit is unlimited. Claims that exceed the timely filing limit deny. Requests to override timely filing must be submitted on paper claims with the ICN of the original denied claim for consideration of payment. 7.1.1 Date Rx Written to Date of Service Edits Claims that exceed the maximum Date Rx Written to Date of Service limit as indicated in Table 7.1.1.1 – Date Rx Written to Date of Service Edits deny with the NCPDP Error Code # M4/“Prescription number/time limit exceeded.” Table 7.1.1.1 – Date Rx Written to Date of Service Edits Description Limit Comments Date Rx Written to First Fill Date 366 days from date written for non-controlled drugs NCPDP Error Code M4/“Prescription number/time limit exceeded” Date Rx Written to First Fill Date 90 days from date written for CII drugs NCPDP Error Code M4/“Prescription number/time limit exceeded” Date Rx Written to First Fill Date 183 days from date written for CIII, CIV, and CV drugs Date Rx Written to Refill Limit 183 days from date written for CIII, CIV, and CV drugs Durations for Controlled Substances NCPDP Error Code M4/“Prescription number/time limit exceeded” NCPDP Error Code M4/“Prescription number/time limit exceeded” 7.1.1.1 Overrides For overrides on claims, reversals, and adjustments billed past the timely filing limits of 366 days or more, pharmacies must contact IDHW. The call center hours are Monday–Friday, 8:00 a.m.–5:00 p.m., MT. 208-364-1829 866-827-9967 Fax: 800-327-5541 Page 24 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual 7.2 Dispensing Limits/Claim Restrictions For current detailed information specifically regarding dispensing limitations and/or claim restrictions, refer to the Magellan Medicaid Administration website at https://idaho.fhsc.com. 7.2.1 Days’ Supply The standard days’ supply maximum is 34 days per prescription with the following exceptions: Exceptions Maintenance list cannot exceed 100 days’ supply Maintenance List 7.2.2 Cardiac glycosides Thyroid replacement hormones Prenatal vitamins Nitroglycerin products, oral, or sublingual Fluoride and vitamin/fluoride combination products Non-legend oral iron salts Oral contraceptives Quantity 7.2.2.1 Minimum Quantity Limits There are no minimum quantity limits. 7.2.2.2 Maximum Quantity Limits, Quantity Per Day, Quantity Over Time, and Maximum Daily Dose For current detailed information specific to these dispensing limits, refer to the Magellan Medicaid Administration website at https://idaho.fhsc.com. 7.2.3 Minimum/Maximum Age Limits For current detailed information specific to these limitations, refer to the Magellan Medicaid Administration website at https://idaho.fhsc.com. 7.2.4 Refills DEA = 0: Original plus up to 99 refills within 366 days from original Date Rx Written. DEA = 2: No refills. Confidential and Proprietary Page 25 State of Idaho Medicaid Pharmacy Claims Submission Manual 7.3 DEA = III-V: Original plus 5 refills within 183 days from original Date Rx Written. Provider Reimbursement 7.3.1 Provider Reimbursement Rates Usual and Customary charges are defined as the lowest charge by the provider to the general public for the same service, including advertised specials. 7.3.1.1 Generic Drugs Pay Lesser Of If state price exists State Price + Dispensing Fee; or Usual & Customary If no state price exists General Agents Acceptance Corporation (GAAC) or FUL + Dispensing Fee; or Usual & Customary If no GAAC exists WAC or FUL + Dispensing Fee; or Usual & Customary If GAAC, WAC, nor state price exists, deny claim with NCPDP Error Code DN – M/I Basis of Cost Determination with additional message “Please contact Myers and Stauffer at 1-800-591-1183.” 7.3.1.2 Brand Drugs Pay Lesser Of If state price exists State Price + Dispensing Fee; or Usual & Customary If no state price exists BAAC + Dispensing Fee; or Usual & Customary If no BAAC exists WAC + Dispensing Fee; or Usual & Customary Page 26 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual If BAAC, WAC, nor state price exists, deny claim with NCPDP Error Code DN – M/I Basis of Cost Determination with additional message “Please contact Myers and Stauffer at 1-800-591-1183.” 7.3.1.3 340b Providers Enter the Acquisition Cost plus the pharmacy’s assigned tiered dispensing fee in the Usual & Customary field. 7.3.2 Provider Dispensing Fees Dispense fees are determined by provider claim volume as submitted on the claim volume survey: Providers with annual claim volume of less than 40,000 = $15.11 Providers with annual claim volume of 40,000–69,999 = $12.35 Providers with annual claim volume of more than 70,000 or that did not participate in claim volume survey = $11.51 Dispense fees will be limited to 1 per GSN per provider every 22 days (exceptions to limit: antibiotics, narcotic analgesics, and stimulant, Therapeutic classes 16, 17 (cough and cold), 31 (anti-parasitics), HIC3 = H7T (Antipsychotics, Atypical, Dopamine & Serotonin Antag), HIC3 = H7X (Antipsychotics, D2 Partial Agonist/5HT Mixed), HIC3 = H2E, H2F (excluding HSN = 001620 Buspar), HSN = 001894 (clonazepam), and GSN = 033724 (Trileptal Suspension). 7.3.3 Payment Error Rate Measurement (PERM) The Centers for Medicare & Medicaid Services (CMS) implemented the PERM program to measure improper payments in the Medicaid and the State Children’s Health Insurance Program (SCHIP). PERM is designed to comply with the Improper Payments Information Act of 2002 (IPIA; Public Law No. 107-300). For PERM, CMS is using contractors to perform statistical calculations, medical records collection, and medical data processing review of Medicaid and SCHIP fee-for-service (FFS) claims. Medical records are needed to support medical reviews that the CMS review contractor conducts on the Medicaid and SCHIP FFS claims to determine whether the claims were correctly paid. It is important that providers cooperate by submitting all requested documentation within the designated timeframe. Failure to provide the requested documentation is in violation of Idaho Code Section 56-209h and the Idaho Medicaid Provider Agreement. • Confidential and Proprietary Providers are required to notify the Department of any changes, including, but not limited to, its mailing address, service locations, and phone number, within 30 days of the date of the change. All providers should check the system to ensure their phone numbers and addresses are correct in the Idaho Medicaid provider file. If not, please request a change immediately to ensure the PERM medical record request can be delivered to the correct address. See Section 2.1 –Enrolling as an IDHW Pharmacy for more information. Page 27 State of Idaho Medicaid Pharmacy Claims Submission Manual Detailed information regarding the PERM program requirements is available online at http://healthandwelfare.idaho.gov/Default.aspx?tabid=214. 7.4 Client Co-Pays Description Medicaid Co-Pay Standard $0.00 7.5 Prior Authorizations 7.5.1 Clinical Prior Authorizations Exceptions Exceptions: ($0.00) Idaho Medicaid continues to receive prior authorization requests for products that have clinical edits. The Magellan Medicaid Administration Pharmacy Support Center handles Early Refill drug overrides for non-controlled products only. If the drug is a controlled substance, the Pharmacy Support Center forwards the request to the IDHW Call Center. 7.5.2 Emergency Protocols Medicaid pays for a 72-hour emergency supply of medications that require a PA if a prior authorization request has not been processed and it is after hours, a weekend, or an IDHWdesignated holiday. An example of when this may occur is the doctor may have submitted the PA request, but it has not been processed yet. The call center hours are Monday–Friday, 8:00 a.m.– 5:00 p.m., MT. 208-364-1829 866-827-9967 Fax: 800-327-5541 Page 28 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual The appropriate PA process must be utilized during regular business hours. All of the following conditions must be met for an emergency supply: The participant is Medicaid-eligible on the date of service. The prescription is new to the pharmacy. The medication requires PA. The days’ supply for the emergency period does not exceed three days. The override codes for billing for a 72-hour emergency supply are Reason for Service code: TP (payer/processor question); Professional Service code: MR (medication review); and Result of Service code: 1F (filled, with different quantity). Emergency overrides are limited to 1 per Generic Sequence Number (GSN) per 30 days per cardholder. • A GSN is a five-digit code that groups together all NDCs that have the same generic chemical composition in the same strength and form. In order for the cardholder to receive the remainder of his/her fills or subsequent refills, a completed PA request must be faxed or the prescriber must call the Medicaid Pharmacy Unit. 7.6 Special Participant Conditions 7.6.1 Lock-In A member may be locked in to a prescriber, pharmacy provider, or both. If the member is locked in to a pharmacy and the claim rejects with “Patient Locked into another Pharmacy” and the rejection occurs during normal IDHW business hours, the pharmacy provider should contact IDHW. Overrides can be requested for one of the following reasons: Lock-in pharmacy is closed. Lock-in pharmacy is out of the prescribed medicine. To receive the override during normal business hours, you must contact the IDHW Medicaid Pharmacy Unit at the following phone numbers: 208-364-1829 866-827-9967 The member can only receive 1 override per 365 days. Page 29 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Overrides for physician lock-ins will not be allowed. Overrides for pharmacy lock-ins will not be allowed outside of IDHW business hours. 7.6.2 Diagnosis Codes/Hospice Recipients If a claim rejects for an NCPDP Error Code of #75 – Prior authorization required, with a supplemental message of “Hospice patient. Please call 208-364-1829 for PA evaluation,” providers will need to call Idaho Clinical Call Center. • 7.7 Effective 12/02/2013, the Provider will no longer be required to enter diagnosis codes on the claim. Compound Claims IDHW processes compounds using the Multi-Ingredient Compound functionality as provided by NCPDP v.D.0. All compounds must contain at least two ingredients, and at least one ingredient must be a covered product. Single-ingredient compound claims are not accepted. Multiple instances of an NDC within a compound are not allowed. Each compound ingredient undergoes all edits relative to the NDC. The total ingredient cost submitted must be equal to the sum of the ingredients’ cost or the claim will deny. The Submission Clarification Code (SCC), (NCPCP Field # 42Ø-DK) = “8” (process compound for approved ingredients), may be submitted at POS to override and pay only covered ingredients within the compound. SCC = “8” does not override the obsolete date of the drug or existing PA requirements. Dispensing fees for compound claims is the standard dispense fee with additional amounts added based on the route of administration. See Section 7.3.2 – Provider Dispensing Fees for the dispense fees. Confidential and Proprietary Page 30 State of Idaho Medicaid Pharmacy Claims Submission Manual 7.7.1 Fields Required for Submitting Multi-Ingredient Compounds On CLAIM SEGMENT Enter COMPOUND CODE (NCPDP Field # 4Ø6-D6) of “2.” Enter PRODUCT CODE/NDC (NCPDP Field # 4Ø7-D7) as “00000000000” on the claim segment to identify the claim as a multi-ingredient compound. Enter QUANTITY DISPENSED (NCPDP Field # 442-E7) of entire product. Enter GROSS AMOUNT DUE (NCPDP Field # 43Ø-DU) for entire product. SUBMISSION CLARIFICATION CODE (NCPDP Field # 42Ø-DK) = Value “8” will only be permitted for POS (not valid for paper claims) and should be used only for compounds. On COMPOUND SEGMENT COMPOUND DOSAGE FORM DESCRIPTION CODE (NCPDP Field # 45Ø-EF) COMPOUND DISPENSING UNIT FORM INDICATOR (NCPCP Field # 451-EG) COMPOUND ROUTE OF ADMINISTRATION (NCPCP Field # 452-EH) COMPOUND INGREDIENT COMPONENT COUNT (NCPCP Field # 447-EC) (Maximum of 25) For Each Line Item COMPOUND PRODUCT ID QUALIFIER (NCPCP Field # 488-RE) of “3” COMPOUND PRODUCT ID (NCPDP Field # 489-TE) COMPOUND INGREDIENT QUANTITY (NCPDP Field # 448-ED) COMPOUND INGREDIENT COST (NCPDP Field # 449-EE) Page 31 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual 8.0 Coordination of Benefits (COB) Coordination of benefits is the mechanism used to designate the order in which multiple carriers are responsible for benefit payments, and thus, prevention of duplicate payments. Third-party liability (TPL) refers to An insurance plan or carrier; A program; and A commercial carrier. The plan or carrier can be An individual; A group; Employer-related; Self-insured; and A self-funded plan. The program can be Medicare, which has liability for all or part of a client’s medical or pharmacy coverage. The terms third-party liability and other insurance are used interchangeably to mean any source other than Medicaid that has a financial obligation for health care coverage. 8.1 COB General Instructions 8.1.1 COB Process All third-party resources (TPRs) available to a Medicaid client must be utilized for all or part of their medical costs before billing to Medicaid. TPRs are any individual, entity, or program that is or may be contractually or legally liable to pay all or part of the cost of any medical services furnished to a client. The provider shall resolve all TPRs before Medicaid can consider paying a claim, even when Medicaid prior authorization has been given. The Department may deny payment of a provider’s claims if the provider fails to apply third-party payments to medical bills, to file necessary claims, or to cooperate in matters necessary to secure payment by insurance or other liable third parties. Providers must comply with all policies of a patient’s insurance coverage, including, but not limited to, prior authorization, quantity, and days’ supply limits. Magellan Medicaid Administration assists IDHW in monitoring this process for compliance on all claims. Idaho Medicaid is always the payer of last resort. Providers must bill all other payers first and then bill Idaho Medicaid. This requirement also applies to compounds. Confidential and Proprietary Page 32 State of Idaho Medicaid Pharmacy Claims Submission Manual Magellan Medicaid Administration supports the use of the COB segment as per the NCPDP version D.0 claim transaction. When COB is not received, a NCPDP Error Code # 41 (Submit Bill to Primary Payer) with Other Payer Name in Additional Message field will be returned. When COB is received, reimbursement is calculated to pay up to the Medicaid allowed amount less the third-party payment. Medicaid co-payments are also deducted for participants subject to Medicaid co-pay. In some cases, this may result in the claim billed to Medicaid being paid at $0.00. 8.1.1.1 COB Denial Edits Claims will deny when the participant has TPL coverage on the eligibility file and the claim is received with no COB segment or Other Coverage Code (OCC). Claims will deny when a COB segment was received with OCC = “2” and the Other Payer Amount = $0. Claims will deny when a COB segment was received with OCC = “2” and the Other Payer Patient Responsibility Amount is not submitted on the claim. Claims will deny when a COB segment is received with OCC = “8.” Claims will deny when the Participant has TPL coverage and a COB segment was received with any of the following conditions: OCC = “3,” “4,” “5,” “6,” or “7” and the Other Payer Amount > $0. OCC = “3” requires the submission of Approved Payer Reject Codes and Count. OCC = “0,” “1,” or “8.” 8.1.1.2 COB Approval Edits If the Pharmacy submits a claim with a valid COB segment for a Participant who has TPL coverage, Magellan Medicaid Administration will adjudicate the claim as follows: When OCC = “2” and the Other Payer Paid amount > $0 and the Other Payer - Patient Responsibility Amount is submitted, the claim is approved for the payment and the net amount to be paid will be the lesser of the Medicaid allowable less other payer payment amount or the Other Payer – Patient Responsibility Amount. When Other Coverage Code, (NCPDP Field # 3Ø8-C8) = “3” or “4” Other Payer Paid amount = $0 and valid Other Payer ID is submitted, the claim is approved for payment and the net amount to be paid will be the ID DHW Medicaid allowable. OCC = “3” will require submission of approved Other Payer Reject Codes and Count. Table 8.1.1.2.1 – TPL Codes displays values and claim dispositions based on pharmacist submission of the standard NCPDP TPL codes. Where applicable, it has been noted which Other Coverage Code (NCPDP Field # 3Ø8-C8) should be used based on the error codes received from the primary. Page 33 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Table 8.1.1.2.1 – TPL Codes Other Coverage Code (Field # 3Ø8-C8) Other Payer Amount Paid (Field # 431-DV) 0 = Not specified must = 0 2 = Other coverage exists, payment collected must be > 0 1 = No other coverage identified 3 = Other coverage exists, claim not covered Notes must = 0 Not allowed for override must = 0 Used when the primary denies the claim for drug not covered Used when payment is collected from the primary The following error codes must be submitted on the claim for override: 4 = Other coverage exists, payment not collected 8 = Co-pay only Confidential and Proprietary must = 0 must = 0 60 Product/service not covered for patient age 61 Product/service not covered for patient gender 65 Patient is not covered 67 Filled before coverage effective 68 Filled after coverage expired 69 Filled after coverage terminated 70 Product/service not covered 76 Plan limitation exceeded 78 Cost exceeds maximum AG Days supply limitations for product/service M1 Patient not covered in this aid category M2 Recipient locked in M4 Prescription/service reference number/time limit exceeded PA Exhausted/not renewable P5 Coupon expired RN Plan limit exceeded on intended partial fill values Used when the primary pays the claim but does not receive anything from the primary due to, for example, deductible; pay and chase Not allowed for override Page 34 State of Idaho Medicaid Pharmacy Claims Submission Manual Page 35 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual 9.0 Appendix A – Idaho D.0 Payer Specification ID_D0_Payer_Spec. pdf http://mmadocs.fhsc.com/Rx/QuikCheks_Payer_Specs/QuikCheks_Payer_Specs.asp Confidential and Proprietary Page 36 State of Idaho Medicaid Pharmacy Claims Submission Manual Page 37 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual 10.0 Appendix B – Universal Claim Form Sample All paper claims must be submitted to Magellan Medicaid Administration on a UCF, which may be obtained from a pharmacy’s wholesaler. Section 13. 0 – Appendix E – Directory/Addresses at the end of this manual specifies (1) an alternative source for universal claim forms, and (2) the Magellan Medicaid Administration address to which pharmacies should mail UCF billings. Confidential and Proprietary Page 38 State of Idaho Medicaid Pharmacy Claims Submission Manual Page 39 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual 11.0 Appendix C – ProDUR 11.1 ProDUR Problem Types ProDUR encompasses the detection, evaluation, and counseling components of pre-dispensing drug therapy screening. The ProDUR system of Magellan Medicaid Administration assists in these functions by addressing situations in which potential drug problems may exist. ProDUR performed prior to dispensing assists the pharmacists to ensure that their patients receive the appropriate medications. Because the Magellan Medicaid Administration ProDUR system examines claims from all participating pharmacies, drugs that interact or are affected by previously dispensed medications can be detected. Magellan Medicaid Administration recognizes that the pharmacists use their education and professional judgments in all aspects of dispensing. ProDUR is offered as an informational tool to aid the pharmacists in performing their professional duties. Listed below are all the ProDUR Conflict Codes within Magellan Medicaid Administration system for the IDHW Medicaid program. Professional Service Codes Allowed for Submission All codes are allowed for all conflict types. Professional Service Code/Description Select one AS/Patient Assessment CC/Coordination of Care DE/Dosing Evaluation/Determination FE/Formulary Enforcement GP/Generic Product Selection M0/Prescriber Consulted MA/Medication Administration MR/Medication Review PH/Patient Medication History PM/Patient Monitoring P0/Patient Consulted PE/Patient Monitoring PT/Perform Laboratory Test RO/Physician Consulted Other Source RT/Recommended Laboratory Tests SC/Self Care Consultation SW/Literature Search/Review TC/Payer/Processor Consulted TH/Therapeutic Product Interchange Confidential and Proprietary Page 40 State of Idaho Medicaid Pharmacy Claims Submission Manual Result of Service Codes Allowed for Submission All codes are allowed for all conflict types. Result of Service Code/Description Select one 1A/filled as is, false positive 1B/filled prescription as is 1C/filled, with different dose 1D/filled, different direction 1E/filled, with different drug 1F/filled, different quantity 1G/filled, prescriber approved 1H/brand-to-generic change 1J/Rx-to-OTC change 1K/filled, different dosage form 2A/prescription not filled 2B/not filled – direction clarified 3A/recommendation accepted 3B/recommendation not accepted 3C/discontinued drug 3D/regimen changed 3E/therapy changed 3F/therapy chg – cost inc accepted 3G/drug therapy unchanged 3H/follow-up report 3J/patient referral 3K/instructions understood 3M/compliance aid provided 3N/medication administered Reason for Service Code DD TD SX Page 41 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual 11.2 Drug Utilization Review (DUR) Fields The following are the ProDUR edits that will deny for IDHW: Deny or Message Only Deny Sev 1 – Deny Sev 2 – Message Sev 3 – Message ProDUR Problem Type Provider Level IDHW Clinical Call Override Allowed Center Override (via NCPDP DUR Required Override Codes) Early Refill (ER) No, Automatic Yes for Controlled Tolerance = 75 percent for all products override if increased dose **For non-controlled, the system will automatically check for an increase in dose and if that is found based on the current and historical claims for the same GSN, the system will not deny the current claim for ER. Drug-to-Drug Interactions (DD) Yes N/A Deny Therapeutic Duplication (TD) Yes N/A Deny Drug-to-Gender (SX) Yes N/A Message Message Sev 1 – Deny Sev 2 – Message Sev 3 – Message Severity 1 Severity 2 Severity 3 Minimum/Maximum Daily Dosing (LD, HD) Drug-to-Disease (MC) Drug-to-Pregnancy Precautions (PG) Confidential and Proprietary N/A N/A No N/A N/A Calls must go to ID pharmacy unit for review Page 42 State of Idaho Medicaid Pharmacy Claims Submission Manual Page 43 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual 12.0 Appendix D – ProDUR and POS Reject Codes Messages After a pharmacy online claims submission, the Magellan Medicaid Administration POS system returns messages that comply with the NCPDP standards. Messages focus on ProDUR and POS rejection codes, as explained in the next sections. 12.1 ProDUR Alerts If a pharmacy needs assistance interpreting a ProDUR alert or denial messages from the Magellan Medicaid Administration POS system, the pharmacy should contact the Pharmacy Support Center at the time of dispensing. Refer to Section 13. 0 – Appendix E – Directory/Addresses at the end of this manual for contact information. The Pharmacy Support Center can provide claims information on all error messages, which are sent by the ProDUR system. This information includes NDCs and drug names of the affected drugs, dates of service, whether the calling pharmacy is the dispensing pharmacy of the conflicting drug, and days’ supply. All ProDUR alert messages appear at the end of the claims adjudication transmission. The following table provides the format that is used for these alert messages. Table D.1.1 – Record Format for ProDUR Alert Messages Format Field Definitions Reason For Service Code Up to three characters – Code transmitted to pharmacy when a conflict is detected (e.g., ER, HD, TD, DD) Other Pharmacy Indicator One character – Indicates if the dispensing provider also dispensed the first drug in question Severity Index Code One character – Code indicates how critical a given conflict is 1 = Your pharmacy 3 = Other pharmacy Previous Date of Fill Eight characters – Indicates previous fill date of conflicting drug in YYYYMMDD format Data Base Indicator One character – Indicates source of ProDUR message Quantity of Previous Fill Confidential and Proprietary Five characters – Indicates quantity of conflicting drug previously dispensed 1 = First DataBank (FDB) 4 = Processor Developed Page 44 State of Idaho Medicaid Pharmacy Claims Submission Manual Format Field Definitions Other Prescriber 12.2 One character – Indicates the prescriber of conflicting prescription 0 = No Value 1 = Same Prescriber 2 = Other Prescriber Point-of-Sale Reject Codes and Messages The following table lists the rejection codes and explanations, possible B1, B2, B3 fields that may be related to denied payment, and possible solutions for pharmacies experiencing difficulties. All edits may not apply to this program. Pharmacies requiring assistance should call the Magellan Medicaid Administration Pharmacy Support Center. Refer to Section 13. 0 – Appendix E – Directory/Addresses at the end of this manual for contact information. Version D.0 Reject Codes for Telecommunication Standard All edits may not apply to this program. Table D.2.1 – Point-of-Sale Reject Codes and Messages Reject Code Explanation ØØ (“M/I” Means Missing/Invalid) Ø2 M/I Version Number Ø1 Ø3 Ø4 Ø5 Ø6 Ø7 Ø8 Ø9 1C 1E 1Ø 11 12 13 14 Page 45 Field Number Possibly in Error M/I BIN 1Ø1 M/I Transaction Code 1Ø3 M/I Processor Control Number M/I Pharmacy Number M/I Group Number M/I Cardholder ID Number M/I Person Code M/I Birth Date M/I Smoker/Non-Smoker Code M/I Prescriber Location Code M/I Patient Gender Code M/I Patient Relationship Code M/I Patient Location M/I Other Coverage Code M/I Eligibility Clarification Code 1Ø2 1Ø4 2Ø1 3Ø1 3Ø2 3Ø3 3Ø4 334 467 3Ø5 3Ø6 3Ø7 3Ø8 3Ø9 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Reject Code Explanation Field Number Possibly in Error 15 M/I Date of Service 4Ø1 17 M/I Fill Number 4Ø3 16 19 2C 2E 2Ø 21 22 23 25 26 28 29 3A 3B 3C 3D 3E 3F 3G 3H 3J 3K 3M 3N 3P 3R 3S 3T 3W 3X M/I Prescription/Service Reference Number M/I Days Supply M/I Pregnancy Indicator M/I Primary Care Provider ID Qualifier M/I Compound Code M/I Product/Service ID M/I Dispense as Written (DAW)/Product Selection Code M/I Ingredient Cost Submitted M/I Prescriber ID M/I Unit of Measure M/I Date Prescription Written M/I Number Refills Authorized M/I Request Type M/I Request Period Date-Begin M/I Request Period Date-End M/I Basis of Request M/I Authorized Representative First Name M/I Authorized Representative Last Name M/I Authorized Representative Street Address M/I Authorized Representative City Address M/I Authorized Representative State/Province Address M/I Authorized Representative Zip/Postal Zone M/I Prescriber Phone Number M/I Prior Authorized Number Assigned M/I Authorization Number Prior Authorization Not Required M/I Prior Authorization Supporting Documentation Active Prior Authorization Exists Resubmit at Expiration of Prior Authorization Prior Authorization In Process Authorization Number Not Found Confidential and Proprietary 4Ø2 4Ø5 335 468 4Ø6 4Ø7 4Ø8 4Ø9 411 6ØØ 414 415 498-PA 498-PB 498-PC 498-PD 498-PE 498-PF 498-PG 498-PH 498-PJ 498-PK 498-PM 498-PY 5Ø3 4Ø7 498-PP 5Ø3 Page 46 State of Idaho Medicaid Pharmacy Claims Submission Manual Reject Code Explanation 3Y Prior Authorization Denied 33 M/I Prescription Origin Code 32 34 35 38 39 4C 4E 4Ø 41 5C 5E 5Ø 51 52 53 54 55 56 58 6C 6E 6Ø 61 62 63 64 65 66 67 68 69 Page 47 Field Number Possibly in Error M/I Level of Service 418 M/I Submission Clarification Code 42Ø M/I Primary Care Provider ID M/I Basis of Cost M/I Diagnosis Code M/I Coordination of Benefits/Other Payments Count M/I Primary Care Provider Last Name Pharmacy Not Contracted With Plan On Date of Service Submit Bill to Other Processor or Primary Payer M/I Other Payer Coverage Type M/I Other Payer Reject Count Non-Matched Pharmacy Number Non-Matched Group ID Non-Matched Cardholder ID Non-Matched Person Code Non-Matched Product/Service ID Number Non-Matched Product Package Size Non-Matched Prescriber ID Non-Matched Primary Prescriber M/I Other Payer ID Qualifier M/I Other Payer Reject Code Product/Service Not Covered for Patient Age Product/Service Not Covered for Patient Gender Patient/Card Holder ID Name Mismatch Institutionalized Patient Product/Service ID Not Covered 419 421 423 424 337 57Ø None None 338 471 2Ø1 3Ø1 3Ø2 3Ø3 4Ø7 4Ø7 411 421 422 472 3Ø2, 3Ø4, 4Ø1, 4Ø7 3Ø2, 3Ø5, 4Ø7 31Ø, 311, 312, 313, 32Ø Claim Submitted Does Not Match Prior Authorization 2Ø1, 4Ø1, 4Ø4, 4Ø7, 416 Patient Age Exceeds Maximum Age 3Ø3, 3Ø4, 3Ø6 Patient Is Not Covered Filled Before Coverage Effective Filled After Coverage Expired Filled After Coverage Terminated 3Ø3, 3Ø6 4Ø1 4Ø1 4Ø1 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Reject Code Explanation Field Number Possibly in Error 7C M/I Other Payer ID 34Ø 7Ø Product/Service Not Covered 4Ø7 7E 71 72 73 74 75 76 77 78 79 8C 8E 8Ø 81 82 83 84 85 86 87 88 89 9Ø 91 M/I DUR/PPS Code Counter Prescriber Is Not Covered Primary Prescriber Is Not Covered Refills Are Not Covered Other Carrier Payment Meets or Exceeds Payable Prior Authorization Required Plan Limitations Exceeded Discontinued Product/Service ID Number Cost Exceeds Maximum Refill Too Soon M/I Facility ID M/I DUR/PPS Level Of Effort Drug-Diagnosis Mismatch Claim Too Old Claim Is Post-Dated Duplicate Paid/Captured Claim Claim Has Not Been Paid/Captured Claim Not Processed Submit Manual Reversal Reversal Not Processed DUR Reject Error Rejected Claim Fees Paid Host Hung Up Host Response Error Confidential and Proprietary 473 411 421 4Ø2, 4Ø3 4Ø9, 41Ø, 442 462 4Ø5, 442 4Ø7 4Ø7, 4Ø9, 41Ø, 442 4Ø1, 4Ø3, 4Ø5 336 474 4Ø7, 424 4Ø1 4Ø1 2Ø1, 4Ø1, 4Ø2, 4Ø3, 4Ø7 2Ø1, 4Ø1, 4Ø2 None None None Host Disconnected Before Session Completed Response Not In Appropriate Format To Be Displayed Page 48 State of Idaho Medicaid Pharmacy Claims Submission Manual Reject Code 92 System Unavailable/Host Unavailable *95 Time Out *97 Payer Unavailable *96 *98 99 AA AB AC AD AE AF AG AH AJ AK AM A9 BE B2 CA CB CC CD CE CF CG CH CI CJ Page 49 Field Number Possibly in Error Explanation Processing Host Did Not Accept Transaction/Did Not Respond Within Time Out Period Scheduled Downtime Connection to Payer Is Down Host Processing Error Do Not Retransmit Claim(s) Patient Spend Down Not Met Date Written Is After Date Filled Product Not Covered Non-Participating Manufacturer Billing Provider Not Eligible To Bill This Claim Type QMB (Qualified Medicare Beneficiary) – Bill Medicare Patient Enrolled Under Managed Care Days’ Supply Limitation for Product/Service Unit Dose Packaging Only Payable for Nursing Home Recipients Generic Drug Required M/I Software Vendor/Certification ID 11Ø M/I Transaction Count 1Ø9 M/I Segment Identification M/I Professional Service Fee Submitted M/I Service Provider ID Qualifier M/I Patient First Name M/I Patient Last Name M/I Cardholder First Name M/I Cardholder Last Name M/I Home Plan M/I Employer Name M/I Employer Street Address M/I Employer City Address M/I Employer State/Province Address M/I Employer Zip Postal Zone 111 477 2Ø2 31Ø 311 312 313 314 315 316 317 318 319 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Reject Code Explanation Field Number Possibly in Error CK M/I Employer Phone Number 32Ø CM M/I Patient Street Address 322 CL CN CO CP CQ CR CW CX CY CZ DC DN DQ DR DT DU DV DX DY DZ EA EB EC ED EE EF EG EH EJ EK EM M/I Employer Contact Name M/I Patient City Address M/I Patient State/Province Address M/I Patient Zip/Postal Zone M/I Patient Phone Number M/I Carrier ID M/I Alternate ID M/I Patient ID Qualifier M/I Patient ID M/I Employer ID M/I Dispensing Fee Submitted M/I Basis of Cost Determination M/I Usual And Customary Charge M/I Prescriber Last Name M/I Unit Dose Indicator M/I Gross Amount Due M/I Other Payer Amount Paid M/I Patient Paid Amount Submitted M/I Date of Injury M/I Claim/Reference ID M/I Originally Prescribed Product/Service Code M/I Originally Prescribed Quantity M/I Compound Ingredient Component Count M/I Compound Ingredient Quantity M/I Compound Ingredient Drug Cost M/I Compound Dosage Form Description Code M/I Compound Dispensing Unit Form Indicator M/I Compound Route of Administration M/I Originally Prescribed Product/Service ID Qualifier M/I Scheduled Prescription ID Number M/I Prescription/Service Reference Number Qualifier Confidential and Proprietary 321 323 324 325 326 327 33Ø 331 332 333 412 423 426 427 429 43Ø 431 433 434 435 445 446 447 448 449 45Ø 451 452 453 454 445 Page 50 State of Idaho Medicaid Pharmacy Claims Submission Manual Reject Code Explanation Field Number Possibly in Error EN M/I Associated Prescription/Service Reference Number 456 ER M/I Procedure Modifier Code 459 EP ET EU EV EW EX EY EZ E1 E3 E4 E5 E6 E7 E8 E9 FO GE HA HB HC HD HE HF HG H1 H2 H3 H4 H5 H6 Page 51 M/I Associated Prescription/Service Date M/I Quantity Prescribed M/I Prior Authorization Type Code M/I Prior Authorization Number Submitted M/I Intermediary Authorization Type ID M/I Intermediary Authorization ID M/I Provider ID Qualifier M/I Prescriber ID Qualifier M/I Product/Service ID Qualifier M/I Incentive Amount Submitted M/I Reason for Service Code M/I Professional Service Code M/I Result of Service Code M/I Quantity Dispensed M/I Other Payer Date M/I Provider ID M/I Plan ID M/I Percentage Sales Tax Amount Submitted M/I Flat Sales Tax Amount Submitted M/I Other Payer Amount Paid Count M/I Other Payer Amount Paid Qualifier M/I Dispensing Status M/I Percentage Sales Tax Rate Submitted M/I Quantity Intended to Be Dispensed M/I Days Supply Intended to Be Dispensed M/I Measurement Time M/I Measurement Dimension M/I Measurement Unit M/I Measurement Value M/I Primary Care Provider Location Code M/I DUR Co-Agent ID 457 46Ø 461 462 463 464 465 466 436 438 439 44Ø 441 442 443 444 524 482 481 341 342 343 483 344 345 495 496 497 499 469 476 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Reject Code Explanation Field Number Possibly in Error H7 M/I Other Amount Claimed Submitted Count 478 H9 M/I Other Amount Claimed Submitted 48Ø H8 JE J9 KE M1 M2 M3 M4 M5 M6 M7 M8 ME MZ NE NN PA PB PC PD PE PF PG PH PJ PK PM PN PP PR PS M/I Other Amount Claimed Submitted Qualifier M/I Percentage Sales Tax Basis Submitted M/I DUR Co-Agent ID Qualifier M/I Coupon Type Patient Not Covered In This Aid Category 479 484 475 485 Recipient Locked In Host PA/MC Error Prescription/Service Reference Number/Time Limit Exceeded Requires Manual Claim Host Eligibility Error Host Drug File Error Host Provider File Error M/I Coupon Number 486 M/I Coupon Value Amount 487 Error Overflow Transaction Rejected at Switch or Intermediary PA Exhausted/Not Renewable Invalid Transaction Count for This Transaction Code 1Ø3, 1Ø9 M/I Clinical Segment 111 M/I Claim Segment M/I COB/Other Payments Segment M/I Compound Segment M/I Coupon Segment M/I DUR/PPS Segment M/I Insurance Segment M/I Patient Segment M/I Pharmacy Provider Segment M/I Prescriber Segment M/I Pricing Segment M/I Prior Authorization Segment M/I Transaction Header Segment Confidential and Proprietary 111 111 111 111 111 111 111 111 111 111 111 111 Page 52 State of Idaho Medicaid Pharmacy Claims Submission Manual Reject Code Field Number Possibly in Error Explanation PT M/I Workers’ Compensation Segment 111 PW Non-Matched Employer ID 333 PV PX PY PZ P1 P2 P3 P4 P5 P6 P7 P8 P9 RA RB RC RD RE RF RG RH RJ RK RM RN RP Page 53 Non-Matched Associated Prescription/Service Date 457 Non-Matched Other Payer ID 34Ø Non-Matched Unit Form/Route of Administration 451, 452, 6ØØ Non-Matched Unit of Measure to Product/Service ID Associated Prescription/Service Reference Number Not Found Clinical Information Counter Out of Sequence 4Ø7, 6ØØ 456 493 Compound Ingredient Component Count Does Not Match Number 447 of Repetitions Coordination of Benefits/Other Payments Count Does Not Match Number of Repetitions 337 Date Of Service Prior to Date of Birth 3Ø4, 4Ø1 Coupon Expired Diagnosis Code Count Does Not Match Number of Repetitions DUR/PPS Code Counter Out of Sequence Field Is Non-Repeatable 486 491 473 PA Reversal Out of Order Multiple Partials Not Allowed Different Drug Entity Between Partial and Completion Mismatched Cardholder/Group ID – Partial To Completion M/I Compound Product ID Qualifier Improper Order Of “Dispensing Status” Code On Partial Fill Transaction M/I Associated Prescription/service Reference Number On Completion Transaction M/I Associated Prescription/Service Date On Completion Transaction Associated Partial Fill Transaction Not On File Partial Fill Transaction Not Supported Completion Transaction Not Permitted With Same “Date Of Service” As Partial Transaction Plan Limits Exceeded On Intended Partial Fill Values Out Of Sequence “P” Reversal On Partial Fill Transaction 3Ø1, 3Ø2 488 456 457 4Ø1 344, 345 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Reject Code Explanation RS M/I Associated Prescription/Service Date On Partial Transaction RU Mandatory Data Elements Must Occur Before Optional Data Elements In a Segment RT R1 R2 R3 R4 R5 R6 R7 R8 R9 SE TE UE VE WE XE ZE Field Number Possibly in Error 457 M/I Associated Prescription/Service Reference Number On Partial 456 Transaction Other Amount Claimed Submitted Count Does Not Match Number 478, 48Ø Of Repetitions Other Payer Reject Count Does Not Match Number of Repetitions 471, 472 Procedure Modifier Code Invalid for Product/Service ID 4Ø7, 436, 459 Procedure Modifier Code Count Does Not Match Number of Repetitions Product/Service ID Must Be Zero When Product/Service ID Qualifier Equals Ø6 Product/Service Not Appropriate for This Location Repeating Segment Not Allowed in Same Transaction Syntax Error 458, 459 4Ø7, 436 3Ø7, 4Ø7, 436 Value in Gross Amount Due Does Not Follow Pricing Formulae 43Ø M/I Compound Product ID 489 M/I Procedure Modifier Code Count M/I Compound Ingredient Basis of Cost Determination M/I Diagnosis Code Count M/I Diagnosis Code Qualifier M/I Clinical Information Counter M/I Measurement Date Confidential and Proprietary 458 49Ø 491 492 493 494 Page 54 State of Idaho Medicaid Pharmacy Claims Submission Manual Confidential and Proprietary Page 55 State of Idaho Medicaid Pharmacy Claims Submission Manual 13.0 Appendix E – Directory/Addresses Contact/Topic Pharmacy Support Center 24/7/365 Contact Numbers 800-922-3987 Mailing, E-mail, and Web Addresses Magellan Medicaid Administration, Inc. 11013 West Broad Street Glen Allen, VA 23060 Purpose/Comments Pharmacy calls for ProDUR questions Non-clinical prior authorization and early refills Questions regarding Payer Specifications, etc. Participant Help Desk Web Support Call Center 6:00 a.m.–6:00 p.m., MT, Monday–Friday 800-241-8276 Vendor Software Certification and Testing 8:00 a.m.–5:00 p.m., ET, Monday–Friday 804-217-7900 For software vendors to test billing transaction sets Idaho Provider Relations IDHW 208-364-1829 866-827-9967 Molina 866-686-4272 208-373-1424 8:00 a.m.–5:00 p.m., MT, Monday– Friday Clinical Prior Authorizations Page 56 Pharmacy calls for Assistance with UAC, Web Claims Submission Password management Navigation Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Contact/Topic Contact Numbers Mailing, E-mail, and Web Addresses Purpose/Comments Molina Provider Record Update (PRU) 866-686-4272 208-373-1424 Fax: 877-517-2041 E-mail: [email protected] PO Box 70082 Boise, ID 83707 Must complete PRU to get paid in the new POS Pharmacy Claims system National Plan and Provider Enumeration System (NPPES) https://nppes.cms.hhs.gov/NPPES/Welcome.do To obtain NPI number Questions from Providers regarding Idaho Pricing Inquiries; State Maximum Allowable Cost (SMAC), Maximum Allowable Cost (MAC), etc. URL http://id.mslc.com/ or Idaho.fhsc.com Click on the Provider tab and select State SMAC List from drop-down window. Myers & Stouffer Website Medicaid Participant Fraud and Abuse 866-635-7515 E-mail: [email protected] Universal Claim Forms CommuniForm Printing 800-869-6508 Durable Medical Equipment (DME) or 866-686-4272 Nutritional Supplements/DME Prior Authorizations Requests Mailing Address for UCF Forms Medicaid Provider Fraud and Abuse Confidential and Proprietary 208-334-5754 http://communiform.com/ncpdp/ Magellan Medicaid Administration. Inc. Idaho Paper Claims Processing Unit P.O. Box 85042 Richmond, VA 23261-5042 DME Specialist Format: UCF Version DAH-2PT E-mail: [email protected] Page 57 State of Idaho Medicaid Pharmacy Claims Submission Manual 14.0 Index A O Appendix, 9, 10, 12, 15, 18, 20, 21, 22, 38, 40, 42, 46, 47, 58 Overrides, 24 B Billing Overview, 8 C Call Center, 6, 10, 11, 21, 28, 44, 58 Claim Format, 8, 12 Claim Formats, 8, 12 P Pharmacy Benefit Manager, 6 Point-of-Sale, 8, 12, 47 POS, 8, 12, 13, 16, 20, 22, 24, 30, 31, 46 Prior Authorizations, 6, 10, 15, 28 Program Specifications, 24 Q Claims, 2, 6, 8, 10, 12, 13, 14, 18, 22, 24, 30, 58, 59 Quantity, 25, 46, 53, 54 Contact, 9, 12, 21, 52, 58 Support, 10, 11, 20, 21, 28, 46, 47, 58 Co-Pays, 28 D Transaction, 13, 15, 16, 20, 47, 51, 55, 56, 57 Data Elements, 14, 56 Universal Claim Form, 8, 12, 18, 40 Dispensing, 12, 25, 27, 30, 52, 53, 54, 56 Website, 9 Compound, 15, 30, 48, 53, 55, 56, 57 Coordination of Benefits, 32, 49 Diagnosis, 17, 18, 30, 49, 50, 56, 57 Dispensing Limits, 25 S T U W E Enrolling, 8 I Introduction, 6 L Lock-In, 29 Page 58 Magellan Medicaid Administration State of Idaho Medicaid Pharmacy Claims Submission Manual Confidential and Proprietary Page 59
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