})(); Chart of 2022 BIN and PCN values for each Medicare Part D prescription drug plan Part 4 of 6 (H5337 through H7322). Restricted products by participating companies are covered as follows: The following are not benefits of the Health First Colorado program: The following are not pharmacy benefits of the Health First Colorado program: The pharmacy benefit manager provides a Pharmacy Support Center to handle clinical, technical, and member calls. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. Members in this eligibility category may receive up to a 12-month supply ofcontraceptiveswith a $0 co-pay. 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. Information on treatment and services for juvenile offenders, success stories, and more. The Client Identification Number or CIN is a unique number assigned to each Medicaid members. The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. What is the Missouri Rx Plan (MORx) BIN/PCN? *Note: Code 09 is a negative amount and is not a valid option for field 351-NP. COVID-19 medications that were procured by the federal government are free of cost to pharmacy providers. during the calendar year will owe a portion of the account deposit back to the plan. Incremental and subsequent fills may not be transferred from one pharmacy to another. MassHealth PBM BIN PCN Group Primary Care Clinician (PCC) Plan Paper claims may be submitted using a pharmacy claim form. Medicaid Director Representation by an attorney is usually required at administrative hearings. Please see the payer sheet grid below for more detailed requirements regarding each field. Provider Payments Information on the direct deposit of State of Michigan payments into a provider's bank account. . A lock icon or https:// means youve safely connected to the official website. Required if Other Payer Amount Paid (431-DV) is greater than zero (0) and Coordination of Benefits/Other Payments Segment is supported. Required if Help Desk Phone Number (550-8F) is used. Each PA may be extended one time for 90 days. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. Children's Special Health Care Services information and FAQ's. All pharmacy PARs must be telephoned, faxed, or submitted via Real Time Prior Authorization via EHR, by the prescribing physician or physician's agent to the Pharmacy Benefit Manager Support Center. Information on child support services for participants and partners. money from Medicare into the account. Members previously enrolled in PCN were automatically enrolled in Medicaid. This form or a prior authorization used by a health plan may be used. Subsequent incremental fills for DEA Schedule II prescription medications are allowed for members residing in a Long Term Care facility based on NCPDP requirements. Required if Other Payer ID (340-7C) is used. Members that meet their monthly co-pay maximum, or 5% of their monthly household income, will be exempt from co-pay for the remainder of that month. Author: jessica.jump Created Date: 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. Sent when Other Health Insurance (OHI) is encountered during claims processing. If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. CMS included the following disclaimer in regards to this data: For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual. There is no registry of PCNs. Commissioner The comments will be reviewed by MDHHS and the Michigan Medicaid Health Plan Common Formulary Workgroup. We are not compensated for Medicare plan enrollments. Members are instructed to show both ID cards before receiving health care services. The Health First Colorado program does not pay a compounding fee. We do not sell leads or share your personal information. 13 = Amount Attributed to Processor Fee (571-NZ). Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Centers for Medicare and Medicaid Services (CMS) - This site has a wealth of information concerning the Medicaid Program. Copies of all RAs, electronic claim rejections, and/or correspondence documenting compliance with timely filing and 60-day rule requirements must be submitted with the Request for Reconsideration. Scroll down for health plan specific information. Any other pharmacy-related questions can be directed to the Medicaid Pharmacy Program at 1-800-437-9101. Please send your comments by March 17, 2023, to: Linda VanCamp, CPhT Formulary Analyst Required for partial fills. New PAs and existing PA approvals that are less than 12 months are not eligible for deferment. Q. enrolled prescribers, pharmacists within an enrolled pharmacy, or their designees). Source of certification IDs required in Software Vendor/Certification ID (110-AK) is Payer Issued, One transaction for B2 or compound claim, Four allowed for B1 or B3, Code qualifying the 'Service Provider ID' (Field # 201-B1), This will be provided by the provider's software vendor, Assigned when vendor is certified with Magellan Rx Management - If not number is supplied, populate with zeros, UNITED STATES AND CANADIAN PROVINCE POSTAL SERVICE. In no case, shall prescriptions be kept in will-call status for more than 14 days. 04 = Amount Exceeding Periodic Benefit Maximum (520-FK) This page provides important information related to Part D program for Pharmaceutical companies. Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. Bridge Card Participation Information on Electronic Benefits for clients and businesses, lists of participating retailers and ATMs, and QUEST. Recursively sort the rest of the list, then insert the one left-over item where it belongs in the list, like adding a . Effective 10/22/2021, Updated policy for Quantity Limit overrides in COVID-19 section. For 8-generic not available in marketplace, 9-plan prefers brand product, or refer to the Colorado Pharmacy Billing Manual, Substitution Allowed - Brand Drug Dispensed as a Generic, Substitution Not Allowed - Brand Drug Mandated by Law, Substitution Allowed - Generic Drug Not Available in Marketplace. Only members have the right to appeal a PAR decision. The CIN is located on all member cards including MMC plan cards. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. Services cannot be withheld if the member is unable to pay the co-pay. The Step Therapy criteria for drugs indicated on the Medicaid Health Plan Common Formulary as requiring ST is below: Medicaid Common Formulary Workgroup Members. 12 -A2 VERSION/RELEASE NUMBER D M 13 -A3 TRANSACTION CODE B1 M 14 -A4 PROCESSOR CONTROL NUMBER Enter "WIPARTD" for SeniorCare , Wisconsin Chronic Disease Program (WCDP ), and AIDS/HIV Drug Assistance Program (ADAP) member s var gcse = document.createElement('script'); 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. 20 = 340B - Indicates that, prior to providing service, the pharmacy has determined the product being billed is purchased pursuant to rights available under Section 340B of the Public Health Act of 1992 including sub-ceiling purchases authorized by Section 340B (a) (10) and those made through the Prime Vendor Program (Section 340B(a)(8)). The FFS Pharmacy Carve-Out will not change the scope (e.g. BIN: 610084 PCN: DRMTUA01 = Test (after 1/1/2012) Processor: Conduent Effective as of: June 1, 2017 NCPDP Telecommunication Standard Version/Release D. 0 NCPDP Data Dictionary Version Date: April 2017 NCPDP External Code List Version Date: April 2017 Updated: March 23, 2021 - - Provider Relations: (800) 365-4944 - - This linkcontains a list ofMedicaid Health Plan BIN, PCN and Group Information. No blanks allowed. 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. The system allows refills in accordance with the number of authorized refills submitted on the original paid claim. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. Health Care Coverage information and resources. Providers who do not contract with the plan are not required to see you except in an emergency. DESI drugs and any drug if by its generic makeup and route of administration, it is identical, related, or similar to a less than effective drug identified by the FDA, Drugs classified by the U.S.D.H.H.S. PCN Phone Fax Email HPMMCD (Medicaid) 866-984-6462 877-355-8070 info@meridianrx.com . These records must be maintained for at least seven (7) years. Since 8-digit IINs are now being assigned, use the first 6 digits of the IIN as the BIN even if the first digit(s) is a zero. 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. BIN - 017804 PCN - ILPOP All claims submitted, including historical reversals and resubmissions after the implementation of the new PBMS, must include the new BIN and PCN. IV equipment (for example, Venopaks dispensed without the IV solutions). Required if needed to supply additional information for the utilization conflict. Copies of all forms necessary for submitting claims are also available on the Pharmacy Resources web page of the Department's website. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. Sent when claim adjudication outcome requires subsequent PA number for payment. Mental illness as defined in C.R.S 10-16-104 (5.5). 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. The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. Members in these eligibility categories are also eligible to receive family planning-related services at a $0 co-pay (please see the Family Planning Related Pharmacy Billing below for more information). If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). Notification of PAR approval or denial is sent to each of the following parties: In addition to stating whether the PAR has been approved or denied, a PAR denial notification letter is sent to members. Required if needed to identify the transaction. The following lists the segments and fields in a Claim Billing or Claim Rebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. Claim with the generic product, NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. A 7.5 percent tolerance is allowed between fills for Synagis. In certain situations, you can. Required if needed to provide a support telephone number to the receiver. Information on adoption programs, adoption resources, locating birth parents and obtaining information from adoption records. Provided for informational purposes only. gcse.async = true; Required if Patient Pay Amount (505-F5) includes deductible. AHCCCS FFS and MCO Contractors BIN, PCN and Group ID's effective 1/1/2022; Tamper Resistant Prescription Pads Memo 11/08/2012 | Rich Text Version & 04/27/2012 | Rich Text . 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 . A Request for Reconsideration will display on the RA as a paid or denied claim without specifying that it is a claim for reconsideration. Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. Date of service for the Associated Prescription/Service Reference Number (456-EN). You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The shaded area shows the new codes. On July 1, 2021, certain beneficiaries were enrolled in NC Medicaid Managed Care health plans, which will include the beneficiarys pharmacy benefits. For TXIX, if the prescriber confirms that the drug was not prescribed in relation to a family planning visit, then the pharmacy should remove the 6-Family Plan from the claim so that the claim can adjudicate accordingly. Drug used for erectile or sexual dysfunction. All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. Those who disenroll Required if needed to provide a support telephone number of the other payer to the receiver. Please visit the OPR section of the Department's website for more detailed information about enrollment and compliance with the Affordable Care Act. It is used when a sender notifies the receiver of drug utilization, drug evaluations, or information on the appropriate selection to process the claim/encounter. This pharmacy billing manual explains many of the Colorado Department of Health Care Policy & Financing's (the Department) policies regarding billing, provider responsibilities, and program benefits. Required on all COB claims with Other Coverage Code of 3. Payer/Carrier BIN/PCN Date Available Vendor Certification ID 4D d/b/a Medtipster 610209/05460000 Current 601DN30Y Adjudicated Marketing 600428/05080000 Current 601DN30Y Alaska Medicaid 009661 Current 091511D002 Providers may submit coverage exception requests by fax, phone or electronically: For BCCHP plans, fax 877-480-8130, call 1-866-202-3474 (TTY/TDD 711) or submit electronically on MyPrime or CoverMyMeds login page. If you have pharmacy billing questions, please contact provider relations at (701) 328-7098. Required when there is payment from another source. Where should I send the Medicare Part D coordination of benefits (COB) claims? 07 = Amount of Co-insurance (572-4U) Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Plan Name/Group Name: Illinois Medicaid BIN: 1784 PCN: ILPOP Processor: Change Healthcare (CHC) Effective as of: September 21, 22 NCPDP Telecommunication Standard Version/Release #: D. NCPDP Data Dictionary Version Date: July 27 NCPDP External Code List Version Date: July 213 Contact/Information Source: 1-877-782-5565 Prescribers are encouraged to write prescriptions for preferred products. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. Information about audits conducted by the Office of Audit. The offer to counsel shall be face-to-face communication whenever practical or by telephone. Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. Members who were formerly in foster care are co-pay exempt until their 26th birthday, Services provided by Community Mental Health Services, Members receiving a prescription for Tobacco Cessation Product. Required if Basis of Cost Determination (432-DN) is submitted on billing. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan. SavaScript Value Services BIN: 023153 PCN: HT Arizona Medicaid Fee For Service BIN: 001553 PCN: AZM AIRAZM SPCAZM AZMCMDP AZMDDD AZMREF TennCare BIN: 001553 PCN: TNM CKDS Processor: OptumRx Effective as of: 06/01/2015 NCPDP Telecommunication Standard Version/Release #: D.0 NCPDP Data Dictionary Version Date: October 2017 NCPDP External Code . Clinical concerns or PDP questions should be directed to (877)3099493 or visit the. Required if Previous Date Of Fill (530-FU) is used. below list the mandatory data fields. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), Required on all COB claims with Other Coverage Code of 3, OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT, Required on all COB claims with Other Coverage Code of 2 or 4, OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER. Required if any other payment fields sent by the sender. ORDHSFFS : Advanced Health 800-788-2949 003585 38900 AllCare ; 800-788-2949 ; 003585 : Submit Prior Authorization requests to Medi-Cal Rx by: Fax to 800-869-4325. Colorado Pharmacy supports up to 25 ingredients. 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 Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. Resources & Links. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. The Pharmacy Carve-Out does not apply to members enrolled in Managed Long-Term Care plans (e.g., MLTC, PACE and MAP), the Essential Plan, or Child Health Plus (CHP). Providers submitting claims using the current BIN and PCN will receive the error messages listed below. 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. Medicaid Managed Care BIN, PCN, and Group 1/1/2019 through 12/31/2019 (pharmacy services carved out of managed care starting 1/1/2020) BIN 610011, PCN IRX, Group SHNNDMEDI If you have pharmacy questions, you may email them to dhsmed@nd.gov. We are an independent education, research, and technology company. Resources and information to assist in assuring firearm safety for families in the state of Michigan. M -Mandatory as defined by NCPDP R -Required as defined by the Processor RW -Situational as defined by Plan Transaction Header Segment: Mandatory Field # NCPDP Field Name Value Req Comment 11-A1 BIN Number 004336, 610591 012114, 013089 020396 Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the plan provider for additional information. All plans must at a minimum cover the drugs listed on the Medicaid Health Plan Common Formulary. Claims that do not result in the Health First Colorado program authorizing reimbursement for services rendered may be resubmitted. Programs for healthy children & families, including immunization, lead poisoning prevention, prenatal smoking cessation, and many others. May be used for cases where Health First Colorado's drug list designates both a brand drug and its generic equivalent as non-preferred products and also designates that the non-preferred brand product is favored for coverage over the equivalent non-preferred generic. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. 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. Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. Prior authorization requirements may be added to additional drugs in the future. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. This value is the prescription number from the first partial fill. PCN: 9999. The PCN (Processor Control Number) is required to be submitted in field 104-A4. Required for 340B Claims. First format for 3-digit Electronic Transaction Identification Number (ETIN): 3-digit ETIN- (Electronic Transaction Identification Number)- (3), 4-digit ETIN- (Electronic Transaction Identification Number)- (4), To initiate the PA process, the prescriber must call the PA call center at (877)3099493 and select option. copayments, covered drugs, etc.) Information on the Family Independence Program, State Disability Assistance, SSI, Refugee, and other cash assistance. This publication provides information regarding the Medicaid Pharmacy Carve-Out, a Medicaid Redesign Team (MRT) II initiative to transition the pharmacy benefit from managed care to the Medicaid Fee-for-Service (FFS) Pharmacy Program. Required for partial fills. MedImpact is the prescription drug provider for all medical Plans. Pharmacies may use the number 8 in Field # 420-DK instead of obtaining a PA for non-covered ingredients to allow the claim to pay for the ingredients that are considered a covered benefit. There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. 10 = Amount Attributed to Provider Network Selection (133-UJ) The new BIN and PCN are listed below. Appeals may be sent to: With few exceptions, providers are required to submit claims electronically. The use of inaccurate or false information can result in the reversal of claims. Effective as of July 1, 2021 NCPDP Telecommunication Standard Version D. NCPDP Data Dictionary Version Date August of 2007 NCPDP External Code List Version Date October 15, 2020 Contact/Information Source www.medimpact.com The following claims can be submitted on paper and processed for payment: Providers can submit only one claim per submission on the PCF, however, compound claims can be submitted. A formulary is a list of drugs that are preferred by a health plan. Required when additional text is needed for clarification or detail. Items that will remain the responsibility of the MC plans include durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) as listed in Sections 4.4, 4.5, 4.6, and 4.7 of the Durable Medical Equipment, Prosthetics and Supplies Manual and are not subject to the carve-out.