Payer Specification Sheet For Prime Therapeutics Commercial Clients

Transcription

1 Specification Sheet For Prime Therapeutics Commercial Clients General information Prime Therapeutics LLC ay 26, 2016 Plan Name BIN PCN BCBS of Alabama Not Required ØØ4915 BCBS of Alabama Work Related Injury Benefit WRI BCBS of Florida Ø12833 FLBC BCBS of North Carolina Ø159Ø5 Not Required BCBS of Illinois ILDR BCBS of Illinois (Blue Script) ILSC BCBS of New exico NDR Ø11552 BCBS of Oklahoma (Drug Card) 1215 BCBS of Oklahoma (Comp Card) 1217 BCBS of Texas BCT Horizon BCBS of New Jersey HZR Horizon BCBS of New Jersey edigap Ø16499 Horizon Casualty Services, Inc Personal Injury Protection HZNPIP Horizon Casualty Services, Inc Workers Compensation HZNWC BCBS of Kansas KSBCS BCBS of Kansas BCBSKS BCBS of innesota HHS BCBS of innesota PGIGN BCBS of innesota (Cenex Harvest) PGNB1 or PGIGN NON BCBS Clients (Carve Out Groups) CARVE BCBS of ontana HBC BCBS of North Dakota NDBCS BCBS of North Dakota (Noridian) NORID BCBS of Nebraska RNEB BCBS of Nebraska (CITY OF OAHA PF DISABLED) PPNI1 Capital Health Plan 61Ø455 ADV Capital Health Plan Dual Eligible ADVD Adient USA, LLC AD General Dynamics GDEP Hormel Foods HOREL IA IAINC JBS JBSPP Jennie-O Turkey Store JENNIE Johnson Controls, Inc JCEP edtronic-covidien DT ississippi State and Employees Life and Health Plan CLAICR University of innesota UPlan UEP BCBS of Wyoming 8ØØØØ1 WYBCS Processor Effective as of: Ø9/Ø1/2Ø11 NCPDP Telecommunication Standard Version/Release #: 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 Page 1 of 9

2 materials are available on Prime s web site. Other versions supported: Will continue to accept NCPDP Telecommunication version 5.1 based upon the CS statement of Discretionary Enforcement until Ø3/3Ø/2Ø12 OTHER TRANSACTIONS SUPPORTED Transaction Code B2 Transaction Name Reversals FIELD LEGEND FOR COLUNS Usage Situation Value Explanation Column Column ANDATORY The Field is mandatory for the No Segment in the designated Transaction. REQUIRED R The Field has been designated with No the situation of "Required" for the Segment in the designated Transaction. QUALIFIED REQUIREENT Required when. The situations designated have qualifications for usage (" 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 REBILL TRANSACTION The following lists the segments and fields in a Billing or Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. 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 NUBER ultiple BIN s listed in General Information Section 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1 1Ø4-A4 PROCESSOR CONTROL NUBER ultiple PCN s listed in General Information Section 1Ø9-A9 TRANSACTION COUNT Ø1-Ø4 Up to 4 transactions per B1 transmissions accepted Page 2 of 9

3 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Ø1-NPI 2Ø1-B1 SERVICE PROVIDER ID 4Ø1-D1 DATE OF SERVICE CCYYDD 11Ø-AK SOFTWARE VENDOR/CERTIFICATION ID Use value for Switch s requirements Insurance Segment Questions Insurance Segment (111-A) = Ø4 3Ø2-C2 CARDHOLDER ID 3Ø6-C6 PATIENT RELATIONSHIP CODE Required for BCBS of OK Comp Card only, BIN Ø11552, PCN 1217 Patient Segment Questions Patient Segment (111-A) = Ø1 Field# NCPDP Field Name Value Usage Situation 3Ø4-C4 DATE OF BIRTH R 3Ø5-C5 PATIENT GENDER CODE R 31Ø-CA PATIENT FIRST NAE Requirement Required for: BCBS of IL, BIN Ø11552, PCN ILSC 311-CB PATIENT LAST NAE R This is required for all other BCBS plans when DOB and gender are identical Segment Questions This payer does not support partial fills Segment (111-A) = Ø7 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1-Rx Billing Page 3 of 9

4 Segment (111-A) = Ø7 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUBER 436-E1 PRODUCT/SERVICE ID QUALIFIER Ø3-National Drug Code (NDC) If billing for a ulti-ingredient Compound, value is ØØ - Not Specified 407-D7 PRODUCT/SERVICE ID NDC Number 442-E7 QUANTITY DISPENSED R 4Ø3-D3 FILL NUBER R 4Ø5-D5 DAYS SUPPLY R 4Ø6-D6 COPOUND CODE 1-Not a Compound 2-Compound R 4Ø8-D8 DISPENSE AS WRITTEN R (DAW)/PRODUCT SELECTION CODE 414-DE DATE PRESCRIPTION WRITTEN R 419-DJ PRESCRIPTION ORIGIN CODE 1-Written R 2-Telephone 3-Electronic 4-Facsimile 5-Pharmacy 354-N SUBISSION CLARIFICATION CODE COUNT aximum count of 3 42Ø-DK SUBISSION CLARIFICATION CODE 8-Process Compound for Approved Ingredients 42-Prescriber ID Submitted is valid and prescribing requirements have been validated. 43- Prescriber's DEA is active with DEA Authorized Prescriptive Right If billing for a ulti-ingredient Compound, value is Ø See Compound Segment for support of multiingredient compounds Submission Clarification Code (42Ø-DK) is used Applies for ulti Ingredient Compound when determined by client or when for Prescriber ID clarification Page 4 of 9

5 Segment (111-A) = Ø7 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 429-DT SPECIAL PACKAGING INDICATOR Applies for ulti Ingredient Compound 461-EU PRIOR AUTHORIZATION TYPE CODE Submit a value of 1 when a PA number is submitted in field 462-EV 462-EV PRIOR AUTHORIZATION NUBER SUBITTED Situation Determined by Client 995-E2 ROUTE OF ADINISTRATION Applies for ulti Ingredient Compound when determined by client Pricing Segment Questions Page 5 of 9

6 Pricing Segment (111-A) = 11 4Ø9-D9 INGREDIENT COST SUBITTED R 438-E3 INCENTIVE AOUNT SUBITTED Required when field 44Ø-E5 is used 426-DQ USUAL AND CUSTOARY CHARGE R 43Ø-DU GROSS AOUNT DUE R Prescriber Segment Questions Prescriber Segment (111-A) = Ø3 466-EZ PRESCRIBER ID QUALIFIER Ø1-NPI R NPI Required 411-DB PRESCRIBER ID R Applicable value for the qualifier used in 466-EZ Coordination of Benefits/Other Payments Segment Questions This Segment is situational Required only for secondary, tertiary, etc claims. Scenario 1 - Other Amount Paid Repetitions Only Coordination of Benefits/Other Payments Segment (111-A) = Ø5 Field # NCPDP Field Name Value Usage 337-4C COORDINATION OF BENEFITS/OTHER aximum PAYENTS COUNT count of C OTHER PAYER COVERAGE TYPE Ø1-Primary- First Ø2-Secondary- Second Ø3-Tertiary- Third Scenario 1 - Other Amount Paid Repetitions Only Situation Page 6 of 9

7 339-6C OTHER PAYER ID QUALIFIER Ø3-Bank Identification Number (BIN) 99-Other This is required when Covered Person s of BCBST s employer group NorthWestern Energy only has secondary coverage with BCBS of T, BIN 61Ø455, PCN HBC 34Ø-7C OTHER PAYER ID 443-E8 OTHER PAYER DATE Coordination of Benefits/Other Payments Segment (111-A) = Ø5 341-HB OTHER PAYER AOUNT PAID COUNT aximum count of HC OTHER PAYER AOUNT PAID Ø7-Drug Benefit QUALIFIER Scenario 1 - Other Amount Paid Repetitions Only 431-DV OTHER PAYER AOUNT PAID Questions This Segment is situational (111-A) = Ø E DUR/PPS CODE COUNTER aximum of 9 occurrences 439-E4 is used REASON FOR SERVICE CODE is used 44Ø-E5 PROFESSIONAL SERVICE CODE A-edication Administration 441-E6 RESULT OF SERVICE CODE is used Page 7 of 9

8 (111-A) = Ø8 is used Compound Segment Questions This Segment is situational Required when Compound Code is =2 Compound Segment (111-A) = 1Ø Field # NCPDP Field Name Value Usage 45Ø-EF COPOUND DOSAGE FOR DESCRIPTION CODE 451-EG COPOUND DISPENSING UNIT FOR INDICATOR 447-EC COPOUND INGREDIENT COPONENT aximum 25 COUNT ingredients 488-RE COPOUND PRODUCT ID QUALIFIER Ø1-Universal Product Code (UPC) Ø3-National Drug Code (NDC) Situation 489-TE COPOUND PRODUCT ID 448-ED COPOUND INGREDIENT QUANTITY 449-EE COPOUND INGREDIENT DRUG COST R Required for each ingredient 49Ø UE COPOUND INGREDIENT BASIS OF COST DETERINATION R Required for each ingredient Clinical Segment Questions This Segment is situational Clinical Segment (111-A) = VE DIAGNOSIS CODE COUNT aximum count of 5 Required When instructed by POS essaging 492-WE DIAGNOSIS CODE QUALIFIER Required When instructed by POS essaging Page 8 of 9

9 Clinical Segment (111-A) = DO DIAGNOSIS CODE Required When instructed by POS essaging Page 9 of 9