Payer Specification Sheet For Prime Therapeutics BCBS of New Mexico Blue Cross Community Centennial (Medicaid)

Transcription

1 Specification Sheet For Prime Therapeutics BCBS of New exico Blue Cross Community Centennial (edicaid) General information Prime Therapeutics LLC January 24, 2018 Plan Name BIN PCN BCBS of New exico Blue Cross Community Centennial Ø11552 SALUD 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 materials are available on Prime s web site. Other versions supported: None 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 Billing/ 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. Page 1 of 8

2 Transaction Header Segment Questions Source of certification IDs required in Software Vendor/Certification ID (11Ø- AK) is Not used Billing/ Transaction Header Segment Billing/ 1Ø1-A1 BIN NUBER See General Info Section 1Ø2-A2 VERSION/RELEASE NUBER DØ 1Ø3-A3 TRANSACTION CODE B1 1Ø4-A4 PROCESSOR CONTROL NUBER See General Info Section BIN listed in General Information Section PCN listed in General Information Section 1Ø9-A9 TRANSACTION COUNT Ø1-Ø4 Up to 4 transactions per B1 transmissions accepted 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 Billing/ Insurance Segment (111-A) = Ø4 Billing/ 3Ø2-C2 CARDHOLDER ID Patient Segment Questions Billing/ Patient Segment (111-A) = Ø1 Billing/ 3Ø4-C4 DATE OF BIRTH R 3Ø5-C5 PATIENT GENDER CODE R 311-CB PATIENT LAST NAE R Page 2 of 8

3 Segment Questions This payer does not support partial fills Billing/ Segment (111-A) = Ø7 Billing/ 455-E PRESCRIPTION/SERVICE REFERENCE NUBER QUALIFIER 1-Rx Billing 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 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 Page 3 of 8

4 Segment (111-A) = Ø7 Billing/ validated. 43- Prescriber's DEA is active with DEA Authorized Prescriptive Right 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 OTHER COVERAGE CODE 1-No Other Coverage 2-Other Coverage Exists-billedpayment collected 3-Other Coverage Billed-claim not covered 4-Other Coverage Existsbilled/payme nt not collected 8- is billing for patient financial responsibility Page 4 of 8 Required for Coordination of Benefits 429-DT SPECIAL PACKAGING INDICATOR Applies for ulti

5 Segment (111-A) = Ø7 Billing/ 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 8- Defined Exemption Situation Determined by Client Pricing Segment Questions Billing/ Pricing Segment (111-A) = 11 Field # NCPDP Field Name Value Usage Billing/ Situation 4Ø9-D9 INGREDIENT COST SUBITTED R 34ØB claims require the actual acquisition cost as purchased under the 34ØB program 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 423-DN BASIS OF COST DETERINATION Ø8-34ØB/Disproportionate Share Pricing/Public Health Service 34ØB claims require the value of Ø8 Prescriber Segment Questions Billing/ Page 5 of 8

6 Prescriber Segment (111-A) = Ø3 Billing/ 466-EZ PRESCRIBER ID QUALIFIER Ø1-NPI R Requirement Prescriber NPI required 411-DB PRESCRIBER ID R Applicable value for the qualifier used in 466-EZ Coordination of Benefits/Other Billing/ 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 339-6C OTHER PAYER ID QUALIFIER Ø3-Bank R Identification Number (BIN) 99-Other 34Ø-7C OTHER PAYER ID R Billing/ Scenario 1 - Other Amount Paid Repetitions Only Situation 443-E8 OTHER PAYER DATE R 341-HB OTHER PAYER AOUNT PAID COUNT aximum count R of HC OTHER PAYER AOUNT PAID QUALIFIER Ø7-Drug Benefit R 431-DV OTHER PAYER AOUNT PAID R DUR/PPS Segment Questions This Segment is situational Billing/ Page 6 of 8

7 DUR/PPS Segment (111-A) = Ø8 Billing/ 473-7E DUR/PPS CODE COUNTER aximum of 9 occurrences DUR/PPS Segment is used 439-E4 REASON FOR SERVICE CODE DUR/PPS Segment is used 44Ø-E5 PROFESSIONAL SERVICE CODE A-edication Administration DUR/PPS Segment is used 441-E6 RESULT OF SERVICE CODE DUR/PPS Segment is used Compound Segment Questions Billing/ 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) Billing/ 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 Billing/ Page 7 of 8

8 Clinical Segment (111-A) = 13 Billing/ 491-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 424-DO DIAGNOSIS CODE Requirement Required When instructed by POS essaging Page 8 of 8