Transcription
.Payer SheetOctober 2019
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyGeneral InformationLine of Business: MedicaidPayer: RxAdvance CorporationBIN: 020545Plan mentIDRXA371PharmacyProvider HelpDesk Phone(800) 671-2276Magnolia Health MedicaidMagnolia Health Medicaid CHIPNebraska Total Care(Heritage 72(800) 671-22764/1/2019RXA374RXGMCNE01N/A(800) 974-5268Pennsylvania Health &Wellness(Community HealthChoices)Buckeye CommunityHealth Plan - Medicaid6/1/2019RXA373RXGMCPA01N/A(800) 681-45726/1/2019RXA375RXGMCOH01N/A(800) 681-5632Buckeye CommunityHealth Plan (MyCare)6/1/2019RXA376RXGMCOH02N/A(800) 681-5632Iowa Total Care7/1/2019(IA Health Link & Hawki)RXA377RXGMCIA01N/A(877) 281-9627Absolute Total Care(Healthy Connections)RXA378RXGMCSC01N/A(800) 930-5512Peach State Health Plan 8/1/2019(Georgia Families,PeachCare for Kids, andPlanning for HealthyBabies)Illinicare Health10/1/2019RXA379RXGMCGA01N/A(800) 518-5973RXA383RXGMCIL01N/A(800) 678-6237Carolina CompleteHealth – MedicaidRXA380RXGMCNC01N/A(800) 518-90727/1/20192/1/2019NCPDP Version: D. ØTechnical Assistance Phone: (508) 804-6980Payer Sheet Version: 1.0M Mandatory; R Required; S Situational; RW Required When KnownPage 2 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyGeneral InformationLine of Business: ExchangePayer: RxAdvance CorporationBIN: 020545NetworkReimbursementIDPharmacyProvider HelpDesk PhoneGo-LiveDatesPCNGA1/1/2020RXA381 RXGMPGA01 N/A(800) 868-3982Ambetter from IllinicareHealth, Insured by CelticInsurance CompanyIL1/1/2020RXA381N/A(800) 863-9317Ambetter from MagnoliaHealthMS1/1/2020RXA381 RXGMPMS01 N/A(800) 779-2869OH1/1/2020RXA381 RXGMPOH01 N/A(800) 691-5206PA1/1/2020RXA381RXGMPPA01 N/A(800) 626-3813SC1/1/2020RXA381 RXGMPNC01 N/A(800) 475-6305Plan NameStateAmbetter from PeachState Health PlanAmbetter from BuckeyeHealth PlanAmbetter from PAHealth & WellnessAmbetter from AbsoluteTotal CareRxGroupRXGMPIL01NCPDP Version: D. ØTechnical Assistance Phone: (508) 804-6980Payer Sheet Version: 1.0M Mandatory; R Required; S Situational; RW Required When KnownPage 3 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyTable of Contents1.Claim Billing – Request . 52.Claim Reversal – Request . 123.Claim Acceptance (Paid/Duplicate of Paid) – Response . 144.Claim Acceptance (Rejected) – Response . 22M Mandatory; R Required; S Situational; RW Required When KnownPage 4 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyField Legend TablePayer Use ColumnMandatoryRequiredSituationalRequired WhenValueMRSRWField Usage Notes The Field is mandatory for the transaction segment.The Field has been designated as "Required" in the transaction segment.Will be specified for requested data in specific situations.“Required When” designated status for a field as required, when data isknown for the condition. This represents some situations which have designated qualifications forusage as "Required when known", "Not required if it is not known”.M Mandatory; R Required; S Situational; RW Required When KnownPage 5 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 Only1. Claim Billing – RequestThe following section of the payer sheet contains details for processing a RxAdvance pharmacy claim billing request perNCPDP D.0 standards. This segment contains working details for the following transaction segments:1.2.3.4.5.6.7.8.9.10.Transaction header segmentInsurance segmentPatient segmentClaim segmentPrescriber segmentCoordination of benefits / Other payments segmentDUR/PPS segmentPricing segmentCompound segmentClinical segmentField #TRANSACTION HEADER SEGMENTValuesPayerUsage(M)1Ø1-A1BIN Number020545M1Ø2-A2Version Release Number1Ø3-A3Transaction CodeB1M1Ø4-A4Processor Control Number(see above)M1Ø9-A9Transaction Count2Ø2-B2Service Provider ID Qualifier2Ø1-B1Service Provider IDM4Ø1-D1Date of ServiceM11Ø-AKSoftware Vendor/Certification IDOField #INSURANCE SEGMENT3Ø2-C2Cardholder ID3Ø1-C1Group ID3Ø3-C3Person CodeCommentMMØ1-NPIValuesUp to 4 transactions. For compoundclaims, only 1 transaction is allowed.MPayerUsage(M)CommentM(see above)3Ø6-C6Patient Relationship CodeField #PATIENT SEGMENT3Ø4-C4Date of Birth Not specified1 Cardholder2 Spouse3 Child4 OtherValuesRWRWRequired to uniquely identify the familymembers within the Cardholder ID.RRequired if needed to uniquely identifythe family members within theCardholder ID.PayerUsage(M)CommentM3Ø5-C5Patient Gender CodeRW31Ø-CAPatient First NameRW311-CBPatient Last NameRM Mandatory; R Required; S Situational; RW Required When KnownPage 6 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyField #PATIENT SEGMENT335-2CPregnancy Indicator35Ø-HNPatient E-Mail AddressValuesPayerUsage(M)Blank - Not Specified1 - Not Pregnant2 – PregnantRWRequired if this field could result indifferent coverage, pricing, or patientfinancial responsibility.RWRequired if this field could result indifferent coverage, pricing, or patientfinancial responsibility.384-4XPatient ResidenceØ - Not Specified1 - Home2 - Skilled Nursing Facility3 - Nursing Facility4 - Assisted Living Facility5 - Custodial Care Facility6 - Group Home9 - Intermediate CareFacility/Mentally Retarded11 - Hospice15 - Correctional InstitutionField #CLAIM SEGMENTValue111-AM4Ø2-D2Segment IdentificationPrescription/Service Reference NumberQualifierPrescription/Service Reference Number436-E1Product/Service ID Qualifier4Ø7-D7Product/Service IDM442-E7Quantity DispensedR4Ø3-D3Fill NumberR4Ø5-D5Days Supply4Ø6-D6Compound Code455-EM1 Rx BillingPayerUsage(M)CommentMMØ3 NDCMR414-DEDispense as Written/Product SelectionCodeDate Prescription Written415-DFNumber of Refills Authorized4Ø8-D8Comment1 Not a Compound2 CompoundØ- 9RRRRØ - Not Known1 - Written2 - Telephone3 - Electronic - used whenprescription obtained via SCRIPTor HL7 Standard transactions.4 - Facsimile5 - Pharmacy –used when apharmacy generates a new Rxnumber from an existing Rxnumber419-DJPrescription Origin Code354-NXSubmission Clarification Code CountRWRequired if Submission ClarificationCode (42Ø-DK) is used.42Ø-DKSubmission Clarification CodeRWRequired if clarification is needed andvalue submitted is greater than zero(Ø).46Ø-ETQuantity PrescribedRWRequired for Coordination of Benefits.3Ø8-C8Other Coverage CodeØ - Not Specified by patient1 - No other coverage2 - Other coverage existspayment collected3 - Other Coverage Billed – claimnot covered4 - Other coverage existspayment not collectedRM Mandatory; R Required; S Situational; RW Required When KnownPage 7 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyField #CLAIM SEGMENTValuePayerUsage(M)Comment8 - Claim is billing for patientfinancial responsibility only429-DTSpecial Packaging Indicator6ØØ-28Unit of Measure418-DILevel of Service461-EUPrior Authorization Type Code462-EVPrior Authorization Number Submitted996-G1147-U7Compound TypePharmacy Service TypeEA - EachGM –ML - MillilitersØ - Not Specified1 - Patient consultation2 - Home delivery3 - Emergency4 - 24 hour service5 - Patient consultation regardinggeneric product selection6 - In-Home ServiceØ - Not Specified1 - Prior Authorization 2- Medical Certification3 - EPSDT (Early PeriodicScreening Diagnosis Treatment)4- Exemption from Copay and/orCoinsurance5 - Exemption from RX6 - Family Planning Indicator7 - TANF (Temporary Assistancefor Needy Families)8 - Payer Defined Exemption9 - Emergency PreparednessØ1 - Anti-infectiveØ2 - IonotropicØ3 - ChemotherapyØ4 - Pain managementØ5 - TPN/PPN (Hepatic, Renal,Pediatric) Total ParenteralNutrition/ Peripheral ParenteralNutritionØ6 - HydrationØ7 - Ophthalmic99 - Other1 - Community/Retail PharmacyServices2 - Compounding PharmacyServices.3 - Home Infusion TherapyProvider Services.4 - Institutional PharmacyServices.5 - Long Term Care PharmacyServices.6 - Mail Order PharmacyServices.7 - Managed Care OrganizationPharmacy Services.8 - Specialty Care PharmacyServices.99 - OtherRWRequired if this field could result indifferent coverage, pricing, or patientfinancial responsibility.RWRequired if this field could result indifferent coverage, pricing, or patientfinancial responsibility.RWRequired to indicate the need forspecial handlingRWRequired to indicate the need forspecial handling to override a normalprocessing rejection.RWRWRequired when pharmacy expects nonstandard reimbursement calculation orspecial processing because of thisvalue. Required for LTC determination.Mail Order and Specialty pharmaciesare required to provide this for properreimbursement.M Mandatory; R Required; S Situational; RW Required When KnownPage 8 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyField #PRESCRIBER SEGMENTValue466-EZPrescriber ID QualifierØ1 National Provider Identifier(NPI)411-DBPrescriber IDPayerUsage(M)CommentRRField #COORDINATION OF BENEFITS /OTHER PAYMENTS SEGMENT337-4CCoordination of Benefits/OtherPayments CountValuePayerUsage(S)CommentMBlank - Not SpecifiedØ1 - PrimaryØ2 - SecondaryØ3 - TertiaryØ4 - QuaternaryØ5 - QuinaryØ6 - SenaryØ7 - SeptenaryØ8 - OctonaryØ9 - NonaryØ3 - Bin Number338-5COther Payer Coverage Type339-6COther Payer ID Qualifier34Ø-7COther Payer IDR443-E8Other Payer DateR341-HBOther Payer Amount Paid CountØ1 DeliveryØ2 ShippingØ3 PostageØ4 AdministrativeØ5 IncentiveØ7 Drug BenefitØ9 Compound Preparation Cost1Ø Sales TaxMRRWRequired if Other Payer Amount PaidQualifier (342-HC) is used.RWRequired if Other Payer Amount Paid(431-DV) is used.Required if other payer has approvedpayment for some/all of the billing342-HCOther Payer Amount Paid Qualifier431-DVOther Payer Amount PaidRW471-5EOther Payer Reject CountRW472-6EOther Payer Reject CodeRW353-NROther Payer-Patient ResponsibilityAmount CountRWRequired if Other Payer-PatientResponsibility Amount Qualifier (351NP) is used.351-NPOther Payer-Patient ResponsibilityQualifierRWRequired if Other Payer-PatientResponsibility Amount (351-NQ) isused.352-NQOther Payer-Patient ResponsibilityAmountRWRequired if necessary for patientfinancial responsibility only billing.Required if Other Payer Reject Code(472-6E) is usedRequired when this prior payer hasREJECTED the claim to indicate thereason for the rejectionRequired if necessary forstate/federal/regulatory agencyprograms.M Mandatory; R Required; S Situational; RW Required When KnownPage 9 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyField #DUR/PPS SEGMENTValuePayerUsage(S)111-AMSegment Identification473-7EDUR/PPS Code CounterRW439-E4Reason for Service CodeRW44Ø-E5Professional Service CodeRW441-E6Result of Service CodeRW474-8EDUR/PPS Level of EffortRWField #PRICING SEGMENT4Ø9-D9Ingredient Cost SubmittedR412-DCDispensing Fee SubmittedRW438-E3Incentive Amount SubmittedRW478-H7Other Amount Claimed SubmittedCountRWValuePayerUsage(M)CommentRequired if DUR/PPS Segment is used.Required when needed by plan forproper adjudication.Required when needed by plan forproper adjudication.Required when needed by plan forproper adjudication.Required when needed by plan forproper adjudication.CommentRequired if its value has an effect onthe Gross Amount Due (43Ø-DU)calculation.Required if its value has an effect onthe Gross Amount Due (43Ø-DU)calculation.Required if Other Amount ClaimedSubmitted Qualifier (479-H8) is used.M Mandatory; R Required; S Situational; RW Required When KnownPage 10 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyField #PayerUsage(M)PRICING SEGMENTValue479-H8Other Amount Claimed SubmittedQualifierØ1 - Delivery CostØ2 - Shipping CostØ3 - Postage CostØ4 - Administrative CostØ9 - Compound Preparation Cost99 - Other48Ø-H9Other Amount Claimed SubmittedRW481-HAFlat Sales Tax Amount SubmittedRW482-GEPercentage Sales Tax AmountSubmittedRW483-HEPercentage Sales Tax Rate SubmittedRWBlank - Not SpecifiedØ2 - Ingredient CostØ3 - Ingredient Cost DispensingFeeRW484-JEPercentage Sales Tax Basis Submitted426-DQUsual and Customary ChargeR43Ø-DUGross Amount DueRField #COMPOUND SEGMENT45Ø-EFCompound Dosage Form DescriptionCode451-EGCompound Dispensing Unit FormIndicatorValueRWPayerUsage(S)M1 Each2 Grams3 MillilitersRequired if Other Amount ClaimedSubmitted (48Ø-H9) is used.Required if its value has an effect onthe Gross Amount Due (43Ø-DU)calculation.Required if its value has an effect onthe Gross Amount Due (43Ø-DU)calculation. Required when flat salestax is applicable toproduct dispensed.Required if its value has an effect onthe Gross Amount Due (43Ø-DU)calculation.Required if Percentage Sales TaxAmount Submitted (482-GE) andPercentage Sales Tax Basis Submitted(484-JE) are used.Required if Percentage Sales TaxAmount Submitted (482-GE) andPercentage Sales Tax Rate Submitted(483-HE) are used.CommentRequired if segment is used.M488-RECompound Ingredient ComponentCountCompound Product ID Qualifier489-TECompound Product IDM448-EDCompound Ingredient QuantityM449-EECompound Ingredient Drug CostRW49Ø-UECompound Ingredient Basis of CostDeterminationRWField #CLINICAL SEGMENT111-AMSegment Identification491-VEDiagnosis Code Count492-WEDiagnosis Code Qualifier447-ECCommentMØ3 - NDCValueMPayerUsage(S)RWØ1 ICD-9Ø2 ICD-1ØRWRequired if needed for receiver claimdetermination when multiple productsare billed.Required if needed for receiver claimdetermination when multiple productsare billed.CommentRequired if Diagnosis Code Qualifier(492-WE) and Diagnosis Code (424DO) are usedRequired if Diagnosis Code (424-DO)is used.M Mandatory; R Required; S Situational; RW Required When KnownPage 11 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyField #424-DOCLINICAL SEGMENTDiagnosis CodeValuePayerUsage(S)RWComment: Required if this field could result indifferent coverage, pricing, patientfinancial responsibility, and/or drugutilization review outcome.M Mandatory; R Required; S Situational; RW Required When KnownPage 12 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 Only2. Claim Reversal – RequestThe following section of the payer sheet contains details for processing a RxAdvance pharmacy claim reversalrequest per NCPDP D.0 standards. This segment contains working details for the following transaction segments:1.2.3.4.Transaction header segmentInsurance segmentClaim segmentCoordination of benefits / Other payments segmentField #TRANSACTION HEADER SEGMENTValuePayerUsage(M)1Ø1-A1BIN Number020545M1Ø2-A2Version Release NumberDØM1Ø3-A3Transaction CodeB2M1Ø4-A4Processor Control Number(see above)M1Ø9-A9Transaction Count2Ø2-B2Service Provider ID Qualifier2Ø1-B1Service Provider IDM4Ø1-D1Date of ServiceM11Ø-AKSoftware Vendor/Certification IDMField #INSURANCE SEGMENT3Ø2-C2Cardholder ID3Ø1-C1Group ID(see above)Field #CLAIM SEGMENTValue111-AM4Ø2-D2Segment IdentificationPrescription/Service Reference NumberQualifierPrescription/Service Reference Number436-E1Product/Service ID QualifierM4Ø7-D7Product/Service IDM455-EMMØ1-NPIValueCommentMultiple reversals in a Transmissionmust be for same patient and sameDate of Service for each transactionto be reversed.MPayerUsage(S)CommentM1 Rx BillingØ3 NDCRWPayerUsage(M)CommentMM4Ø3-D3Fill NumberRW3Ø8-C8Other Coverage CodeRWRequired if needed for reversals whenmultiple fills of the samePrescription/Service ReferenceNumber (4Ø2- D2) occur on the sameday.Required if needed by receiver tomatch the claim that is beingreversed.M Mandatory; R Required; S Situational; RW Required When KnownPage 13 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyField #CLAIM SEGMENTValue147-U7Pharmacy Service Type1 - Community/Retail PharmacyServices.2 - Compounding PharmacyServices.3 - Home Infusion TherapyProvider Services.4 - Institutional PharmacyServices.5 - Long Term Care PharmacyServices.6 - Mail Order PharmacyServices.7 - Managed Care OrganizationPharmacy Services.8 - Specialty Care PharmacyServices.99 - OtherField #COORDINATION OF BENEFITS /OTHER PAYMENTS SEGMENTValue111-AM337-4C338-5CSegment IdentificationCoordination of Benefits/Other PaymentsCountOther Payer Coverage TypePayerUsage(M)RWPayerUsage(S)CommentRequired when the submitter mustclarify the type of services beingperformed as a condition for properreimbursement by the payer.CommentMMUsed to identify the specific claimwhen we have processed multipleiterations of the claims (example:Primary and Secondary, Primary andTertiary, Secondary and Quaternary,etc.)M Mandatory; R Required; S Situational; RW Required When KnownPage 14 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 Only3. Claim Acceptance (Paid/Duplicate of Paid) – ResponseThe following section of the payer sheet contains details for processing a RxAdvance pharmacy claim acceptance (paid /duplicate of paid) response request per NCPDP D.0 standards. This segment contains working details for the followingtransaction segments:1.2.3.4.5.6.7.8.9.Response transaction header segmentResponse message header segmentResponse insurance header segmentResponse patient identification segmentResponse status segmentResponse claim segmentResponse pricing segmentResponse DUR/PPS segmentResponse Coordination of benefits / Other payers Release NumberTransaction CodeTransaction CountHeader Response StatusService Provider Id QualifierDØB1Same value as in requestA AcceptedSame value as in requestPayerUsage(M)MMMMM2Ø1-B14Ø1-D1Service Provider IdDate Of ServiceSame value as in requestSame value as in requestMMField #Field #5Ø4-F4Field #3Ø1-C1RESPONSE TRANSACTIONHEADER SEGMENTRESPONSE MESSAGEHEADER SEGMENTValueValueMessageRESPONSE INSURANCEHEADER SEGMENTValueGroup Id(see Required if text is needed for clarification or detail.CommentRequired if needed to identify the actualcardholder or employer group, to identifyappropriate group number, when available.Required to identify the actual group that wasused when multiple group coverages exist.524-FOPlan IdRWRequired if needed to identify the actual planparameters, benefit, or coverage criteria,when available.Required to identify the actual plan ID that wasused when multiple group coverages exist.Required if needed to contain the actual plan IDif unknown to the receiver.M Mandatory; R Required; S Situational; RW Required When KnownPage 15 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyField #545-2FRESPONSE INSURANCEHEADER SEGMENTValueNetwork Reimbursement ID(see above)PayerUsage(S)RWCommentRequired if needed to identify the network forthe covered member.Required if needed to identify the actualNetwork Reimbursement ID, when applicableand/or available.Required to identify the actual NetworkReimbursement ID that was used whenmultiple Network Reimbursement IDs exist.31Ø-CAPatient First NamePayerUsage(S)RW311-CBPatient Last NameRWField #Field #112-AN5Ø3-F3547-5FRESPONSE PATIENTIDENTIFICATION SEGMENTRESPONSE STATUSSEGMENTValueValueTransaction ResponseStatusAuthorization NumberP Paid D Duplicate of PaidApproved Message CodeCountMaximum count of 5.CommentRequired if known.Required if known.PayerUsage(M)CommentMRWRequired if needed to identify thetransaction.RWRequired if Approved Message Code (5486F) is used.M Mandatory; R Required; S Situational; RW Required When KnownPage 16 of 26
RxAdvance D.O Payer Sheet October 2019RxBIN 020545 OnlyField #RESPONSE ed Message CodeBlank - Not SpecifiedØØ1 - Generic AvailableØØ2 - Non-Formulary DrugØØ3 - Maintenance DrugØØ4 - Filled During Transitio
Provider Help Desk Phone Ambetter from Peach State Health Plan GA 1/1/2020 RXA381 RXGMPGA01 N/A (800) 868-3982 Ambetter from Illinicare Health, Insured by Celtic Insurance Company IL 1/1/2020 RXA381 RXGMPIL01 N/A (800) 863-9317 Ambetter from Magnolia Health MS RXA3811/1/2020 RXGMP
