Payer Specification Sheet For Prime Therapeutics BCBS of Illinois Blue Cross Community ICP and FHP (Medicaid)

Transcription

1 Payer Specification Sheet For Prime Therapeutics BCBS of Illinois Blue Cross Community ICP and FHP (edicaid) General information Prime Therapeutics LLC December 1, 2017 Plan Name BIN PCN BCBS of Illinois Blue Cross Community Ø11552 ILCAID Processor Effective as of: Ø9/Ø1/2Ø11 NCPDP Telecommunication Standard Version/elease #: D.Ø NCPDP Data Dictionary Version Date: July 2ØØ7 NCPDP External Code List Version Date: October 2Ø14 Contact/Information Source: Prime Contact Center Phone number 8ØØ Other reference materials are available on Prime s web site. Other versions supported: None OTHE TANSACTIONS SUPPOTED Transaction Code B2 Transaction Name eversals FIELD LEGEND FO COLUNS Payer Value Explanation Column Column ANDATOY The Field is mandatory for the No Segment in the designated Transaction. EQUIED The Field has been designated with No the situation of "equired" for the Segment in the designated Transaction. QUALIFIED EQUIEENT. The situations designated have qualifications for usage ("equired if x", "Not required if y"). Yes Fields that are not used in the transactions and those that do not have qualified requirements (i.e. not used) are excluded from the template. CLAI BILLING/CLAI EBILL TANSACTION The following lists the segments and fields in a Billing or Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Page 1 of 9

2 Transaction Header Segment Questions Source of certification IDs required in Software Vendor/Certification ID (11Ø- AK) is Not used Transaction Header Segment 1Ø1-A1 BIN NUBE ultiple BIN s listed in General Information Section 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1 1Ø4-A4 POCESSO CONTOL NUBE ultiple PCN s listed in General Information Section 1Ø9-A9 TANSACTION COUNT Ø1-Ø4 Up to 4 transactions per B1 transmissions accepted 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Ø1-NPI 2Ø1-B1 SEVICE POVIDE ID 4Ø1-D1 DATE OF SEVICE CCYYDD 11Ø-AK SOFTWAE VENDO/CETIFICATION ID Use value for Switch s requirements Insurance Segment Questions Insurance Segment (111-A) = Ø4 3Ø2-C2 CADHOLDE ID Patient Segment Questions Patient Segment (111-A) = Ø1 3Ø4-C4 DATE OF BITH 3Ø5-C5 PATIENT GENDE CODE Page 2 of 9

3 PATIENT SEGENT SEGENT IDENTIFICATION (111-A) = Ø1 311-CB PATIENT LAST NAE Segment Questions This payer does not support partial fills Segment (111-A) = Ø7 455-E PESCIPTION/SEVICE EFEENCE 1-x Billing NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUBE 436-E1 PODUCT/SEVICE ID QUALIFIE Ø3-National Drug Code (NDC) Page 3 of 9 If billing for a ulti-ingredient Compound, value is ØØ -Not Specified 4Ø7-D7 PODUCT/SEVICE ID NDC Number 442-E7 QUANTITY DISPENSED 4Ø3-D3 FILL NUBE 4Ø5-D5 DAYS SUPPLY 4Ø6-D6 COPOUND CODE 1-Not a Compound 2-Compound 4Ø8-D8 DISPENSE AS WITTEN (DAW)/PODUCT SELECTION CODE 414-DE DATE PESCIPTION WITTEN 419-DJ PESCIPTION OIGIN CODE 1-Written 2-Telephone 3-Electronic 4-Facsimile 5-Pharmacy 354-N SUBISSION CLAIFICATION CODE COUNT aximum count of 3 42Ø-DK SUBISSION CLAIFICATION CODE 2Ø- 34ØB - Indicates that, prior to providing service, the pharmacy has If billing for a ulti- Ingredient Compound, value is Ø See Compound Segment for support of multiingredient compounds equired if Submission Clarification Code (42Ø-DK) is used Applies for ulti Ingredient Compound when determined by

4 Segment (111-A) = Ø7 determined the product being billed is purchased pursuant to rights available under Section 34ØB of the Public Health Act of 1992 including sub-ceiling purchases authorized by Section 34ØB (a)(1ø) and those made through the Prime Vendor Program (Section 34ØB(a)(8)). 42-Prescriber ID Submitted is valid and prescribing requirements have been validated. 43-Prescriber's DEA is active with DEA Authorized Prescriptive ight 45-Prescriber s DEA is a valid Hospital DEA with Suffix and has prescriptive authority for this drug DEA Schedule 46-Prescriber's DEA has prescriptive authority for this drug DEA Schedule 49-Prescriber does not currently have an active Type 1 NPI 3Ø8-C8 OTHE COVEAGE CODE 1-No Other Coverage 2-Other client, 340B claim processing or for Prescriber ID clarification equired for Coordination of Page 4 of 9

5 Segment (111-A) = Ø7 Coverage Exists-billedpayment collected 3-Other Coverage Billed-claim not covered 4-Other Coverage Existsbilled/payment not collected 8- is billing for patient financial responsibility Benefits 429-DT SPECIAL PACKAGING INDICATO Applies for ulti Ingredient Compound 461-EU PIO AUTHOIZATION TYPE CODE Submit a value of 1 when a PA number is submitted in field 462-EV 462-EV PIO AUTHOIZATION NUBE Situation Determined by Client 995-E2 OUTE OF ADINISTATION Applies for ulti Ingredient Compound Pricing Segment Questions Pricing Segment (111-A) = 11 Field # NCPDP Field Name Value Payer 4Ø9-D9 INGEDIENT COST 34ØB claims require the lesser of the actual acquisition cost as purchased under the 34ØB program or HFS 340B allowable 412-DC DISPENSING FEE Page 5 of 9

6 Pricing Segment (111-A) = 11 Field # NCPDP Field Name Value Payer submitting 34ØB claims 438-E3 INCENTIVE AOUNT field 44Ø-E5 is used 481-HA 482-GE FLAT SALES TA AOUNT PECENTAGE SALES TA AOUNT provider is claiming sales tax provider is claiming sales tax 483-HE PECENTAGE SALES TA ATE submitting Percentage Sales Tax ate Submitted (483-HE) and Percentage Sales Tax Basis Submitted (484-JE) provider is claiming sales tax 484-JE PECENTAGE SALES TA BASIS submitting Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Basis Submitted (484-JE) provider is claiming sales tax 426-DQ USUAL AND CUSTOAY CHAGE 43Ø-DU GOSS AOUNT DUE 423-DN BASIS OF COST DETEINATION Ø8-34ØB/Disproportionate Share Pricing/Public Health Service submitting Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax ate Submitted (483-HE) equired for 34ØB claims Page 6 of 9

7 Prescriber Segment Questions Prescriber Segment (111-A) = Ø3 466-EZ PESCIBE ID QUALIFIE Ø1-NPI NPI equired 411-DB PESCIBE ID Payer Applicable value for the qualifier used in 466-EZ Coordination of Benefits/Other Payments Segment Questions This Segment is situational equired only for secondary, tertiary, etc claims. Scenario 1 - Other Payer Amount Paid epetitions Only Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Field # NCPDP Field Name Value Payer 337-4C COODINATION OF BENEFITS/OTHE aximum PAYENTS COUNT count of C OTHE PAYE COVEAGE TYPE Ø1-Primary- First Ø2-Secondary- Second Ø3-Tertiary- Third Coordination of Benefits/Other Payments Segment (111-A) = Ø C OTHE PAYE ID QUALIFIE Ø3-Bank Identification Number (BIN) 99-Other 34Ø-7C OTHE PAYE ID Scenario 1 - Other Payer Amount Paid epetitions Only Scenario 1 - Other Payer Amount Paid epetitions Only 443-E8 OTHE PAYE DATE 341-HB OTHE PAYE AOUNT PAID COUNT aximum count of 9 Page 7 of 9

8 342-HC OTHE PAYE AOUNT PAID QUALIFIE Ø7-Drug Benefit 431-DV OTHE PAYE AOUNT PAID DU/PPS Segment Questions This Segment is situational DU/PPS Segment (111-A) = Ø E DU/PPS CODE COUNTE aximum of 9 occurrences Page 8 of 9 Payer equired if DU/PPS Segment is used 439-E4 EASON FO SEVICE CODE Payer equired if DU/PPS Segment is used 44Ø-E5 POFESSIONAL SEVICE CODE A- edication Administration Payer equired if DU/PPS Segment is used 441-E6 ESULT OF SEVICE CODE Payer DU/PPS Segment is used Compound Segment Questions This Segment is situational Compound Code is =2 Compound Segment (111-A) = 1Ø Field # NCPDP Field Name Value Payer 45Ø-EF COPOUND DOSAGE FO DESCIPTION CODE 451-EG COPOUND DISPENSING UNIT FO INDICATO 447-EC COPOUND INGEDIENT COPONENT aximum 25 COUNT ingredients 488-E COPOUND PODUCT ID QUALIFIE Ø1-Universal Product Code (UPC) Ø3- National Drug Code (NDC) 489-TE COPOUND PODUCT ID

9 Compound Segment (111-A) = 1Ø Field # NCPDP Field Name Value Payer 448-ED COPOUND INGEDIENT QUANTITY 449-EE COPOUND INGEDIENT DUG COST equired for each ingredient 49Ø -UE Compound Segment (111-A) = 1Ø COPOUND INGEDIENT BASIS OF COST DETEINATION Clinical Segment Questions This Segment is situational Clinical Segment (111-A) = VE DIAGNOSIS CODE COUNT aximum count of 5 equired When instructed by POS essaging 492-WE DIAGNOSIS CODE QUALIFIE equired When instructed by POS essaging 424-DO DIAGNOSIS CODE Payer equirement equired When instructed by POS essaging Page 9 of 9