CO Pharmacy Billing Manual - Colorado Pharmacy Billing Manual 0.8_11... This pharmacy billing manual

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Transcript of CO Pharmacy Billing Manual - Colorado Pharmacy Billing Manual 0.8_11... This pharmacy billing manual

  • Colorado Department of Health Care Policy and Financing Medical Assistance Program: Pharmacy Billing Manual Version 0.9

    August 21, 2018

  • Page 2 | Colorado Department of Health Care Policy and Financing Medical Assistance Program Pharmacy Billing Manual

    Table of Contents

    Pharmacy Requirements and Benefits ................................................................................................4 1990 OBRA Rebate Program ...............................................................................................................4 Prior Authorization Request (PAR) Process .........................................................................................4

    Medications Requiring a PAR ................................................................................................................... 5 Guidelines Used by the Department for Determining PAR Criteria ......................................................... 5 Generic Mandate ...................................................................................................................................... 6

    Dispensing Requirements ...................................................................................................................7 Refill Too Soon Policy ............................................................................................................................... 7 Tamper Resistant Prescription Pads ......................................................................................................... 7 Compounded Prescriptions ...................................................................................................................... 7 Partial Fills and/or Prescription Splitting .................................................................................................. 8 Emergency Three-Day Supply ................................................................................................................... 8 Lost/Stolen/Damaged/Vacation Prescriptions ......................................................................................... 9 Counseling ................................................................................................................................................ 9 Dispense As Written (DAW) Override Codes .......................................................................................... 10

    Co-payment Exclusions ...................................................................................................................... 12 Reversals ............................................................................................................................................. 12

    Retention of Records .............................................................................................................................. 12 340B Claims Processing .......................................................................................................................... 13 Mail Order .............................................................................................................................................. 13

    Restricted Products .......................................................................................................................... 14 Exclusions ........................................................................................................................................ 15 Pharmacy Helpdesk.......................................................................................................................... 16 Billing Information ........................................................................................................................... 17

    Timely Filing Requirements .................................................................................................................... 17 Rebilling Denied Claims .......................................................................................................................... 17

    Reuse of Rx Numbers ......................................................................................................................... 18 Delayed Processing by Third Party Payers ......................................................................................... 18 Retroactive Member Eligibility ........................................................................................................... 18 Delayed Notification to the Pharmacy of Eligibility ........................................................................... 19 Extenuating Circumstances ................................................................................................................ 19

    Request for Reconsideration .................................................................................................................. 19 Appealing Reconsideration Denials .................................................................................................... 20

    Paper Claim Submission Requirements ............................................................................................. 21 Instructions for Completing the Pharmacy Claim Form ...................................................................... 22

    Electronic Claim Submission Requirements ........................................................................................... 25 D.0 General Information .................................................................................................................. 26

  • Page 3 | Colorado Department of Health Care Policy and Financing Medical Assistance Program Pharmacy Billing Manual

    Transactions Supported .......................................................................................................................... 26 Field Legend for Columns ....................................................................................................................... 26

    Claim Billing/Claim Rebill Transaction ............................................................................................... 27 Response Claim Billing/Claim Rebill Payer Sheet Template ................................................................ 40

    Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response ............................................ 40 General Information ............................................................................................................................... 40 Claim Billing/Claim Rebill PAID (or Duplicate of PAID) Response ........................................................... 40 Claim Billing/Claim Rebill Accepted/Rejected Response........................................................................ 47 Claim Billing/Claim Rebill Rejected/Rejected Response......................................................................... 53

    NCPDP Version D.0 Claim Reversal Template .................................................................................... 56 Request Claim Reversal Payer Sheet Template ...................................................................................... 56 General Information ............................................................................................................................... 56 Claim Reversal Transaction..................................................................................................................... 56

    Response Claim Reversal Payer Sheet Template ................................................................................ 60 Claim Reversal Accepted/Approved Response ...................................................................................... 60 General Information ............................................................................................................................... 60 Claim Reversal Accepted/Approved Response ...................................................................................... 60 Claim Reversal Accepted/Rejected Response ........................................................................................ 63 Claim Reversal Rejected/Rejected Response ......................................................................................... 66

    Revision History ............................................................................................................................... 68

  • Page 4 | Colorado Department of Health Care Policy and Financing Medical Assistance Program Pharmacy Billing Manual

    Pharmacy Requirements and Benefits This pharmacy billing manual explains many of the Colorado Department of Health Care Policy and Financing’s (hereafter referred to as “the Department”) policies regarding billing, provider responsibilities, and Colorado Medical Assistance Program benefits. Providers should also consult the Code of Colorado Regulations (10 C.C.R. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements.

    1990 OBRA Rebate Program Federal regulation requires that drug manufacturers sign a national rebate agreement with the Centers for Medicaid and Medicare Services (CMS) to participate in the state Medical Assistance Program. Drugs produced by companies that have signed a rebate agreement (participating companies) are generally a Colorado Medical Assistance Program benefit but may be subject to restrictions. In addition, some products are excluded from coverage and are listed in the Restricted Products section. The Medical Assistance Program does not provide reimbursement for products by manufacturers that have not signed a rebate agreement unless the Depar