downloaded - Maryland Pharmacy Programs

Affiliated Computer Services

Pharmacy Provider

Claims Processing Manual for

Maryland Pharmacy

Programs:

Maryland Medical Assistance Program (MA)

Maryland AIDS Disease Assistance Program (MADAP)

Breast and Cervical Cancer Diagnosis and Treatment

(BCCDT)

Kidney Disease Program (KDP)

Administered By:

Affiliated Computer Services, Inc

Government Healthcare Solutions

Revised 12/28/2006

TABLE OF CONTENTS

Page

Section I

INTRODUCTION...........................................................................................................1

Section II

START UP........................................................................................................................2

Section III

MARYLAND TELEPHONE NUMBERS AND ADDRESSES...................................3

KDP TELEPHONES .......................................................................................................4

Section IV

SERVICE SUPPORT.......................................................................................................5

Section V

PROGRAM SET-UP

MA, MPAP & MPDP Claim Format..............................................................................6

Maryland KDP Claim Format.........................................................................................6

Media Options ..................................................................................................................6

Networks ...........................................................................................................................6

Transaction Types.............................................................................................................7

MA, MPAP & MPDP Timely Filing Limits ...................................................................8

MA, MPAP & MPDP Date Rx Written To Date of Service Edits ................................8

KDP Timely Filing Limits ................................................................................................8

KDP Date Rx Written To Date of Service Edits ............................................................8

Required Data Elements...................................................................................................9

Identification Numbers ....................................................................................................9

Section VI

COORDINATION OF BENEFITS - MEDICAL ASSISTANCE AND KDP............10

Section VII

MARYLAND PROGRAM PARTICULARS

Dispensing Limits ............................................................................................................16

Dispense Fees....................................................................................................................18

Mandatory Generic Requirements..................................................................18

Drug Coverage...................................................................................................19

Prior Authorization...........................................................................................21

TABLE OF CONTENTS

Recipient Payment Information.......................................................................23

Medicare Recipients..........................................................................................24

Extemporaneously Compounded Claims........................................................25

Compounded Home Infusion (Home IV) Claims ...........................................25

Long Term Care Claims ...................................................................................26

Hospice ...............................................................................................................26

2

Maryland Medicaid Pharmacy Program Provider Manual

Section VIII

KDP PROGRAM PARTICULARS

Dispensing Limits ..............................................................................................28

Dispense Fees.....................................................................................................29

Mandatory Generic Requirements..................................................................30

Drug Coverage...................................................................................................31

Prior Authorization...........................................................................................33

Recipient Payment Information.......................................................................34

KDP Recipient with Medical Assistance Coverage ......................................34

Compound Claims.............................................................................................34

Long Term Care Claims, Hospice, Spend-down ............................................34

Paper...................................................................................................................34

Section IX

PROSPECTIVE DRUG UTILIZATION REVIEW..................................................35

Section X

EDITS............................................................................................................................38

Appendix

PAYER SPECIFICATION APPENDIX A

OTHER CARRIER CODE LIST APPENDIX B

MARYLAND FORMS APPENDIX C



Pharmacy Compound Invoice



Standard Invoice for all IV Compounds



Standard Prescription/Invoice For Antihemophilic Products



Nutritional Supplement Pre-Auth form for Tube-Fed Patients and Patients with an

Inborn

Error of Metabolism

 Prescriber’s Statement of Medical Necessity - Synagis®

 Prescriber’s Statement of Medical Necessity - Serostim®

 Physician’s Statement of Medical Necessity - Growth Hormone Therapy Initiation

 Physician’s Statement of Medical Necessity - Growth Hormone Therapy Continuation

3


INTRODUCTION

Maryland Medicaid (MA), Breast and Cervical Cancer Drug and Treatment (BCCDT),

Kidney Disease (KDP) and Maryland AIDS Diagnosis Assistance Program (MADAP) programs have contracted with AFFILIATED COMPUTER SERVICES, INC. to process all pharmacy claims using an enhanced point of sale (POS) system. This program will allow participating pharmacies real-time access to recipient eligibility, drug coverage, pricing and payment information, Prior Autorizations using our SmartPA technology , and prospective drug utilization review (ProDUR) across all network pharmacies.

Pharmacy providers must be enrolled through the Medical Assistance Program and the

Kidney Disease Program (KDP) and have an active status for any dates of service submitted. This manual is intended to provide pharmacy claims submission guidelines to the users of the Affiliated Computer Services’ (ACS) on-line system as well as to alert pharmacy providers to new or changed program information. Affiliated Computer

Services’ on-line system is used in conjunction with the pharmacy’s existing system.

While there are a variety of different operating pharmacy systems, the information contained in this manual addresses only the response messages related to the interaction with ACS’ on-line system, not the technical operation of the pharmacy-specific system.

AFFILIATED COMPUTER SERVICES, INC. provides assistance through the Technical

Call Center, which is available 24 hours a day, seven days a week. For answers to questions that are not addressed in this manual or if additional information is needed, contact AFFILIATED COMPUTER SERVICES, INC. at:

1 - (800) 884-3238

1 - (800) 884-7387 (Nationwide Toll Free Number)

AFFILIATED COMPUTER SERVICES, INC. looks forward to working with you to ensure the success of the Maryland Pharmacy Programs, Breast and Cervical Cancers

Diagnosis and Treatment, Maryland AIDS Drug Assistance Program and Kidney Disease

Programs.

4


Implementation

Effective February 4, 2007, all Maryland Pharmacy Programs, BCCDT, MADAP and

KDP pharmacy claims should be processed through AFFILIATED COMPUTER

SERVICES, INC. according to the specifications included in this manual. Check with your software vendor to ensure your system is ready to process according to the payer specifications. The State of Maryland will continue to provide payment and remittance advice on a weekly basis.

Affiliated Computer Services, Inc. will include provisions for the following groups within the Maryland Medicaid Pharmacy Program:

1.

Non-waiver eligible Medical Assistance recipients;

2.

Non-waiver eligible Medical Assistance recipients in long-term care facilities;

3.

Specialty Mental Health drugs for waiver and non-waiver eligible

Medical Assistance recipients;

4.

Other drugs as determined by the Department for waiver eligible medical assistance recipients;

5.

PAC Program recipients;

6.

Kidney Disease Program recipients;

7.

Maryland AIDS Drug Assistance Program recipients;

8.

Breast and Cervical Cancer Diagnosis and Treatment Program recipients; and,

9.

Other recipients as determined by the Department

5


TELEPHONE NUMBERS AND ADDRESSES

Maryland Medical Assistance: 410-767-1755

410-767-1739 DME/DMA

410-767-6028 Timely Filing Limit

Maryland AIDS Drug Assistance Program: 410-

Breast and Cervical Cancer Diagnosis and Treatment: 410-767-6787

Kidney Disease Program: 410-767-5006

Help Desk Responsibility Phone Numbers / Email Availability

Recipient Refer recipients to their caseworker.

Member Help Desk MD (410) 767-5800

(800) 492-5231

8:00am - 5:00pm M-F

Member Help Desk for Maryland Pharmacy Program ( ACS will not be providing this service)

FHS (800) 226-2142 7:00am – 7:00pm M-F,

Excluding State Holidays

Healthchoice Enrollment/HMO Enrollment

MD (800) 977-7388 7:00am – 7:00pm M-F

Enrollee Action Line

MD (800) 284-4510 7:30am – 5:30pm M-F

Technical Call Center for Providers

ACS (800) 884-3238 24/ 7/ 365 1-800-392-3918

ProDur (800) 884-7387 24/ 7/ 365

Prior Authorization Technical Call Center

ACS (800) 884-3238 24/ 7/ 365 1-800-392-3918

MCOA MD/ MCOA (410) 767-1693

(800) 492-6008

24 x 7 x 365

CAMP Office MD (410) 706-3431 M-F, 9:00 am – 4:30 pm

EVS System MD (410) 333-3020 (Baltimore Area)

(410) 333-3021 (Baltimore Area)

(800) 492-2134 (Maryland toll free)

24/ 7/ 365

6


Note: If you have any questions regarding your current NABP/ NCPDP Provider

Number, or if you need to obtain an NABP/ NCPDP, please contact the NCPDP offices directly at 480-477-1000. The NABP/ NCPDP Pharmacy Provider Number (field # 201-

B1) will be required for all claim submissions.

SERVICE SUPPORT

ON-LINE SYSTEM NOT AVAILABLE:

If for any reason the on-line system is not available, providers should submit claims when the on-line capability resumes. In order to facilitate this process, the provider’s software should have the capability to submit backdated claims.

TECHNICAL PROBLEM RESOLUTION:

In order to resolve technical problems, providers should follow the steps outlined below:

1. Check the terminal and communications equipment to ensure that electrical power and telephone services are operational. Call the telephone number the modem is dialing and note the information heard (i.e. fast busy, steady busy, recorded message). Contact the software vendor if unable to access this information in the system.

2. If the pharmacy provider has an internal Technical Support Department, the provider should forward the problem to that department. The pharmacy’s technical support staff will coordinate with Affiliated Computer Services to resolve the problem.

3. If the pharmacy provider’s network is experiencing technical problems, the pharmacy provider should contact the network’s technical support area. The network’s technical support staff will coordinate with AFFILIATED COMPUTER SERVICES, INC. to resolve the problem.

4. If unable to resolve the problem after following the steps outlined above, the pharmacy provider should contact the AFFILIATED COMPUTER SERVICES, INC. Technical

Call Center at:

MA, MDAP, BCCDT & KDP 1-(800) 932-3918

(Nationwide Toll Free Number)

7


MA, MDAP, KDP & BCCDT CLAIM FORMAT:



MA, MPAP & MPDP will require use of NCPDP v.5.1; AFFILIATED COMPUTER

SERVICES, INC. will not accept any lower versions.



The batch format is NCPDP Batch 1.1. – not currently used by any Maryland programs



The paper claim format for MA, MADAP, KDP & BCCDT is Maryland’s proprietary form on the website. Not all programs accept Paper Claims – see later information for program specifics.

MEDIA OPTIONS:



MA, MADAP, KDP & BCCDT Media options include POS, Direct lease line to

Affiliated Computer Services, Paper, and FTP. Paper is for exceptional processing only.

TRANSACTION TYPES:

The following transaction codes are defined according to the standards established by the

National Council for Prescription Drug Programs (NCPDP). Ability to use these transaction codes will depend on the pharmacy’s software. At a minimum, all providers should have the capability to submit original claims (Transaction Code B1) and reversals

(Transaction Code B2). Additionally, AFFILIATED COMPUTER SERVICES will also accept re-bill claims (Transaction Code B3). Please refer to Appendix A,B, C, and D for each program’s specific Payer Specifications.

Full Claims Adjudication (Transaction Code B1)

This transaction captures and processes the claim and returns to the pharmacy the dollar amount allowed under the Maryland Medicaid reimbursement formula.

Claims Reversal (Transaction Code B2)

8


This transaction is used by the pharmacy to cancel a claim that was previously processed.

To submit a reversal, the provider has to void a claim that has received a Paid status. To reverse a claim, the provider selects the Reversal (Void) option in the pharmacy’s computer system.

Claims Re-bill (Transaction Code B3)

This transaction is used by the pharmacy to adjust and resubmit a claim that has previously been processed and received a Paid status. A “claims re-bill” voids the original claim and resubmits the claim within a single transaction.

REQUIRED DATA ELEMENTS :

The AFFILIATED COMPUTER SERVICES, INC. system has program-specific

‘mandatory/ required’, ‘optional / Required When’ and ‘not sent’ data elements for each transaction. The pharmacy provider’s software vendor will need the program specific

Payer Specifications before setting up the plan in the pharmacy’s computer system. This will allow the provider access to the required fields. Please note the following descriptions regarding data elements:



Mandatory = required at all times by NCPDP for the transaction;



Situational = It is necessary to send these fields in noted situations. Some fields designated as situational by NCPDP may be required for all MARYLAND Medicaid transactions.



M or S***R*** = The “R***” indicates that the field is repeating. One of the other designators, Mandatory ‘M’, ‘or Situational ‘S’ will precede it.

Maryland Medicaid, KDP, BCCDT and MADAP pharmacy claims will not be processed without all the required data elements. Required fields may or may not be used in the adjudication process. The complete Payer Specifications, including NCPDP field number references, is in Appendix A, B, C and D.

IDENTIFICATION NUMBERS:



BIN # :

610084 – ALL PROGRAMS

610084 (Coordinated ProDUR)

9




Processor Control #:

Maryland Medicaid DRMDPROD

BCCDT DRBDPROD

MADAP DRMAPROD

DRKDPROD KDP



Group #:

Maryland Medicaid MDMEDICAID

KDP

BCCDT

MADAP

MARYLANDKDP

MDBCCDT

MADAP



Provider ID #:

NCPDP / NABP Number – All Programs



Prescriber ID #:

The system will take the following steps if the DEA number submitted on the claim is not found:

1.

Deny the claim with NCPDP edit 25 (Missing/Invalid Prescriber ID) message

2.

The provider may then either: a.

Resubmit the claim with a valid DEA number; or b.

Call the ACS Call Center and request assistance in determining the Prescriber DEA number c.

If no valid DEA number is found, the Call Center will provide a dummy DEA number



Cardholder ID #:

The system will ensure each recipient has his/her own identification number depending on which program they belong to (i.e. – MADAP, Breast Cancer, etc). In the case of a newborn child please follow the rules below:

The system will ensure claims for newborns will be submitted with the newborn’s ID:

1.

Claims cannot be submitted with the mother’s ID.

2.

If the mother is eligible, there is presumptive eligibility for the newborn. The pharmacist must hold the claims until such time as the newborn has an ID number.

10


Maryland Medicaid MD Medicaid ID Number

KDP

BCCDT

MADAP

Recipient Number & 5 leading zeros

BCCDT Recipient ID

MADAP ID



Product Code National Drug Code (NDC)

TIMELY FILING LIMITS:

( Definition:

“Timely Filing Limits” indicates the maximum timeframe from DOS to the date the claim is entered into the processing system.)

Most providers submit their point of sale claims at the time of dispensing. However there may be legitimate reasons that require a claim to be submitted after the fact. For such instances the following limits are in place:

1. Original claims (NCPDP transaction B1) 279 days

2. Reversal and Re-bill claims (NCPDP transactions B2 and B3) 279 days

Note: Claims that exceed the prescribed timely filing limit will deny.

Requests for timely filing limit overrides should be directed to

Maryland Medical Assistance at (410) 767-6028.

DATE WRITTEN TO DATE OF SERVICE EDITS:

This edit applies to original DOS prescriptions and not refills. The amount of time between the DATE RX WRITTEN (NCPDP field # 414-DE) and the DATE OF

SERVICE (NCPDP field # 401-D1) may not exceed the following:



If DEA = 2 (CII) – 5 (CV), then 30 days.



If DEA = 0, then 120 days.

KDP TIMELY FILING LIMITS:

1. Original claims (NCPDP transaction B1) 183 days

2. Reversal and Re-bill claims (NCPDP transactions B2 and B3) 183 days

Note: Claims that exceed the prescribed timely filing limit will deny. Overrides are not allowed for Timely Filing Limits.

KDP DATE RX WRITTEN TO DATE OF SERVICE EDITS:



This edit applies to original DOS prescription and not refills.



The amount of time between the DATE RX WRITTEN and the DATE OF SERVICE may not be greater than 10 days.

11


Coordination of Benefits (COB)



On-line COB (cost avoidance) will be a part of this program.



If MA, MADP, BCCDT & KDP is the patient’s secondary carrier, claims for COB

(coordination of benefits) will be accepted.



MA, MPAP & MPDP are always the payer of last resort, except for Kidney Disease

Program. (KDP insists that they are always the payer of last resort)



Other coverage will be identified by the presence of other carrier information on the recipient eligibility file and/ or information communicated by the provider on the claim.

The system will deny a claim if the recipient shows other coverage on the DOS and will return error 41 (bill other processor), a carrier code identifying the other carrier, the patient’s policy number and the carrier name in the additional message text field if no other coverage information is submitted on the claim.

Note 1: BCCDT will return a carrier ID of “77777” for Medicare D and a carrier ID of

“88888” for all other carriers

Note 2 : MADAP will not return carrier information

The system will deny claims for recipients with more than one active other carrier and will return the first carrier code on file in the response if not all other coverage information is submitted on the claim. Once the first carrier information is entered then the second line of information, and continue until all carriers have been submitted.



If the recipient shows other coverage on the DOS, AFFILIATED COMPUTER

SERVICES, INC will deny the claim. AFFILIATED COMPUTER SERVICES, INC.

12


will return a unique client-identified carrier code identifying the other carrier, the patient’s policy number and the carrier name in the additional message field. It is possible that a recipient may have more than one active other carrier; in that case,

AFFILIATED COMPUTER SERVICES, INC.

would initially return the code of the first hit; subsequent codes will be returned until fully exhausted. Providers will be required to submit this code in the OTHER PAYER ID (NCPDP field #340-7C) field as part of the override process (see the TPL Processing Grid ) .



Even if no “other insurance” is indicated on the eligibility file, AFFILIATED

COMPUTER SERVICES, INC. will process the claim as a TPL claim if the pharmacist submits TPL data as indicated in the TPL

Processing Grid.



If other insurance is indicated on the eligibility file, then ACS will process as TPL regardless of what TPL codes the pharmacist submits as indicated on the TPL Processing

Grid.



In all cases, AFFILIATED COMPUTER SERVICES, INC. will use the MA, MPAP &

MPDP “Allowed Amount” when calculating payment.

Note: In some cases, this may result in a ‘0’ payment.



Providers are allowed to override days supply limits and/ or Drug Requires PA conditions by entering a ‘5’ (exemption from prescription limits) in the Prior Auth Type

Code field (NCPDP field # 416- DG).

Note: This override situation applies to TPL processing only.



The Maryland Medicaid ID Card indicates if the recipient has other insurance, but it does not specify the name of the other carrier. Following are values and claim dispositions based on pharmacist submitted submission of the standard NCPDP TPL codes.

The Maryland KDP ID Card does NOT indicate if the recipient has other insurance.



Following are values and claim dispositions based on pharmacist submitted submission of the standard NCPDP TPL codes.

TPL PROCESSING GRID v. 5.1:

Other

Coverage

Code (field #

308-C8)

0 = Not

Specified

Other

Payer

Amount

Paid

(field #

431-

DV)

0

Other

Coverage indicated on

Maryland

Pharmacy

Programs

Recipient

Record

Yes

Other

Payer

Date

(field #

443-E8)

M/I or null

13


Other

Payer ID

(field #

340-7C)

Claim

Disposition

M/I or null

Deny, Bill

Primary, M/I

Other Payer

Date

Comments

This code will not override

TPL.

Other

Coverage

Code (field #

308-C8)

Other

Payer

Amount

Paid

(field #

431-

DV)

0 0 = Not

Specified

0 = Not

Specified

0 = Not

Specified

>0

>0

Other


Maryland

Pharmacy

Programs

Recipient

Record

No

Other

Payer

Date

(field #

443-E8)

Null

 No M/I or null

 Yes M/I or null

1 = No other coverage identified








0

0

0

>0

>0

0

0

0

Yes

Yes

No

No

Yes

Yes

No

No

M/I or null

Valid

Date

M/I or null

M/I or null

M/I or null

Valid

Date

Valid

Date

M/I or null

Other

Payer ID

(field #

340-7C)

Claim

Disposition

Null

M/I or null

M/I or null

M/I or null

M/I or null

Valid

TPL

Carrier

Code

Valid

TPL

Pay

Deny, M/I

Other Payer

Date

Deny, M/I

Other Payer

Date

Date,M/I

Other Payer

Comments

M/I or null

M/I or null

M/I or null

Valid TPL

Carrier

Code

Deny, M/I Other

Payer Date

Deny, Bill Primary,

M/I Other Payer

Date, M/I Other

Payer Amount

Deny, Bill

Primary, M/I

Other Payer

Date

Pay

M/I or null

Pay

Use when primary does not show coverage.

1 = No other coverage

0 Yes M/I or null

14


Deny, M/I Other

Payer Date, M/I

Other Payer

Amount




Payer Amount



Date

Other

Coverage

Code (field #

308-C8)

Other

Payer

Amount

Paid

(field #

431-

DV) identified

Other


Maryland

Pharmacy

Programs

Recipient

Record



2 = Other coverage exists, payment collected

0

0

> 0

Yes

Yes

Yes or No

Other

Payer

Date

(field #

443-E8)



2 = Other coverage

>0

>0

No

Yes Valid

Date

>0 Yes or No M/I or null

15


Other

Payer ID

(field #

340-7C)

Claim

Disposition

Comments

Valid

Date

Date >

Adjudicat ion Date

Valid

Date

Valid

Date

Carrier

Code

Invalid

TPL

Carrier

Code

Valid TPL

Carrier

Code

Valid

TPL

Carrier

Code

M/I or null

Date

Deny, Bill

Primary

Deny, M/I

Other Payer

Date

Pay

(Will pay when all

Carriers have been overridden)

Deny, M/I

Other Payer

Date

Will pay the difference between the

Maryland

Pharmacy

Programs

Allowed

Amount and the Other

Payer Amount

(and optionally the

Patient Paid

Amount).

M/I or null

Valid

TPL

Deny, Bill

Primary, M/I

Other Payer

Date

Deny, M/I

Other Payer

Other

Coverage

Code (field #

308-C8)

Other

Payer

Amount

Paid

(field #

431-

DV) exists, payment collected





3 = Other coverage exists, this claim not covered

0

0

>0

>0

0

Other


Maryland

Pharmacy

Programs

Recipient

Record

No

Yes

Yes

Yes

Yes or No

Other

Payer

Date

(field #

443-E8)

M/I or null

N/A

Valid

Date

Valid

Date

Other

Payer ID

(field #

340-7C)

Carrier

Code

M/I or null

N/A

Invalid

TPL

Carrier

Code

Valid

TPL

Carrier

Code

Claim

Disposition

Date

Date, M/I

Other Payer

Date, MI

Other Payer

Amount




Payer Amount

Deny, Bill

Primary

Denial >

Adjudicat ion Date

Valid TPL

Carrier

Code

Deny, M/I

Other Payer

Date

Pay

Comments

Pay the

Maryland

Pharmacy

Programs

Allowed

Amount.


3 = Other

0 No Valid

Date

0 Yes Valid

16


M/I

M/I

Deny, M/I

Other Payer

Date

Deny, Bill

Other

Coverage

Code (field #

308-C8)

Other

Payer

Amount

Paid

(field #

431-

DV)

Other


Maryland

Pharmacy

Programs

Recipient

Record

Other

Payer

Date

(field #

443-E8)

Other

Payer ID

(field #

340-7C)

Claim

Disposition coverage exists, this claim not covered







3 = Other coverage

0

>0

>0

>0

>0

>0

>0

Yes or No

 No

 Yes

 Yes or

No

 Yes

 No

 Yes or

Date

M/I or null

M/I or null

M/I or null

Valid

Valid

Valid

Invalid

17


Valid

TPL

Carrier

Code

M/I or null

M/I or null

Valid

Primary, M/I

Other Payer

Date

Deny, M/I

Other Payer

Date

Deny M/I

Other Payer

Date, M/I

Other Payer

Amount




Payer Amount

Deny, M/I Other

Payer Amount

Invalid Deny, Bill

Invalid

Valid

Primary, M/I

Other Payer

Amount

Deny, M/I

Other Payer

Amount

Deny, M/I

Other Payer

Comments

Other

Coverage

Code (field #

308-C8)

Other

Payer

Amount

Paid

(field #

431-

DV)

Other


Maryland

Pharmacy

Programs

Recipient

Record

No

Other

Payer

Date

(field #

443-E8) exists, this claim not covered



4 = Other coverage exists, payment not collected




4 = Other coverage exists,

0

0

>0

>0

>0

>0

>0

Yes

Yes

 No

 Yes

 Yes or

No

 Yes

 No

Valid

Date

Denial >

Adjudicat ion Date

M/I or null

M/I or null

Valid

Valid

Valid

18


Other

Payer ID

(field #

340-7C)

Claim

Disposition

Invalid

TPL

Carrier

Code

M/I or null

M/I or null

Valid

Date, M/I

Other Payer

Amount

Deny, Bill Primary

Payer

Valid TPL

Carrier

Code

Deny, M/I Other

Payer Date

Deny, M/I Other

Payer Date, M/I

Other Payer

Amount




Payer Amount

Deny, M/I Other

Payer Amount

Invalid Deny, Bill

Primary, M/I

Other Payer

Amount

Invalid Deny, M/I

Other Payer

Amount

Comments

Other

Coverage

Code (field #

308-C8)

Other

Payer

Amount

Paid

(field #

431-

DV)

Other


Maryland

Pharmacy

Programs

Recipient

Record

Other

Payer

Date

(field #

443-E8)

Other

Payer ID

(field #

340-7C) payment not collected







4 = Other coverage exists, payment not

>0

0

0

0

0

0

0

Yes

Yes

No

Yes or No

Yes

Yes

 Yes or

No

Invalid

Valid

Date

Valid

Date

Valid

Date

M/I or null

Valid

Date

Date >

Adjudicat ion Date

19


Valid

Valid

TPL

Carrier

Code

M/I or null

M/I or null

Valid

TPL

Carrier

Code

Invalid

TPL

Carrier

Code

Valid TPL

Carrier

Code

Claim

Disposition

Deny, M/I

Other Payer

Date, M/I

Other Payer

Amount

Pay

Deny, Bill

Primary, M/I

Other Payer

Date

Deny, M/I

Other Payer

Date

Deny, M/I

Other Payer

Date

Deny, Bill

Primary

Deny, M/I

Other Payer

Date

Comments

Use if primary is full deductible or

100% copay.

Other

Coverage

Code (field #

308-C8)

Other

Payer

Amount

Paid

(field #

431-

DV)

Other


Maryland

Pharmacy

Programs

Recipient

Record

Other

Payer

Date

(field #

443-E8)

Other

Payer ID

(field #

340-7C)

Claim

Disposition

Comments collected

New 5.1 codes:

5 = Managed care plan denial

6 = Other coverage denied – not a participating provider

7 = Other coverage exists – not in effect on

DOS

Deny, Drug

Not Covered

Additional

Message:

OCC 5/ 6 Not

Allowed for

Override

Deny, Drug

Not Covered

Additional

Message:

OCC 5/ 6 Not

Allowed for

Override

8 = Claim is billing for copay

NOTE: Copay only Claim Submissions will only be allowed for BCCDT and MADAP recipients. The process and required fields are outlined in each individual section of this manual.

Multi-Line Compound Claim Submission

20


Maryland Medicaid only accepts Multi-line Compound claims. If providers submit a compound claim with a single ingredient the claim will be denied.

The system will accept up to 40 line items (individual ingredients) in each compound claim. The system will allow providers to use Submission Clarification code 8 (process compound for approved ingredients) to override denials for compound ingredients that are not covered.

Duplicate claim Processing

The system will use the following standard methodology to determine Duplicate paid claims:

Response Status: D (retransmission NCPDP Duplicate Response)

Match on: Pharmacy ID (NCPDP field # 201-B1), RX # (NCPDP field

#402-D2), Patient ID (NCPDP field #302-C2), NDC (NCPDP field #407-

D7), DOS (NCPDP field #401-D1) and New/Refill Code (NCPDP field

#601-57)

Error 83: Duplicate RX

Match on: Pharmacy ID (NCPDP field # 201-B1), RX # (NCPDP field

#402-D2), Patient ID (NCPDP field #302-C2), GSN (Not on claim; FDB) and DOS (NCPDP field #401-D1)

Error: 83: Different Pharmacy Search

Match on: RX # (NCPDP field #402-D2), Patient ID (NCPDP field #302-

C2), GSN (Not on claim; FDB) and DOS (NCPDP field #401-D

Error 83: Duplicate Fill

Match on: Patient ID (NCPDP field #302-C2), GSN (Not on claim; FDB) and DOS (NCPDP field #401-D1)

21


767-1693.

DISPENSING LIMITS:

Days Supply:



There is a per claim days supply maximum of 34 days. Quantity dispensed should be commensurate to the days supply.

Exceptions:



Maintenance drugs allow 100 days supply –

BCCDT allows a 102 day supply for Maintenance Drugs.



All Schedule II Narcotics



Leuprolide 3-month kit



Insulin Syringes



Cardiac Drugs



Hypotensive agents



Vasodilating Agents



Potassium supplements



Diuretics



Insulins



Sulfonylureas



Thyroid Agents



Vitamins



Phenytoin and Phenytoin Sodium



Oral products in which ferrous sulfate is the only active ingredient



Chewable tablets of any ferrous salt when combined with vitamin C, multivitamins, multivitamins and minerals, or other minerals in the formulation



14 day supply = Helidac and Clozaril (clozapine).



120 day supply = Sodium Fluoride and Leuprolide 4 month kit.



180 day supply = Oral and Systemic Contraceptives.



Requests to override Days Supply are directed to Maryland Medical Assistance at (410)

22


Refills:

ACS will ensure the following rules for refills

· Non-Controlled Covered Drugs:

1.

Max 11 refills

2.

Max 360 days supply total with refills

3.

Do not allow a refill on a prescription to be filled 360 days or more from the date prescribed.

· Controlled Covered Drugs- Schedules III, IV and V:

1.

Max 5 refills

2.

Max 180 days supply total with refills

3.

Do not allow a refill on a prescription to be filled 180 days or more from the date prescribed.

4.

Do not fill original prescription greater than 30 days from the day prescribed

· Controlled Covered Drugs- Schedule II

1.

No refills allowed

2.

Max 100 days supply on the original prescription

3.

Do not fill original prescription greater than 30 days from the day prescribed

Emergency Fill – Guidelines

The system will allow emergency fills when claims contain a ‘3’ in the Level of Service field (emergency).

1.

Pharmacy Program recipients will be allowed two 72-hour emergency fills per

Rx for non-PDL drugs.

2.

Nursing Home recipients will be allowed a 30 days supply of non-PDL drugs

MANDATORY GENERIC REQUIREMENTS:

Maryland Medicaid, MADAP, BCCDT and KDP have a mandatory generic substitution policy.

Accepted DAW codes for MD Medicaid and KDP are:

DAW 0

DAW 1

DAW 5

DAW 6

23


Accepted DAW codes for BCCDT and MADAP are:

DAW 0

DAW 1

DAW 5

If a claim for a drug is identified as a brand is submitted with a DAW = 1, the claim will deny for NCPDP error code 75, ‘PA Required, Brand Medically Necessary’.

Requests to override (PA) Brand Medically Necessary will be handled by the

Affiliated Computer Services’ Technical Call Center, with the exception of drugs that should be referred to Maryland for further clinical evaluation, or to Affiliated Computer

Services, Inc. for additional PA processing.

PROSPECTIVE DRUG UTILIZATION REVIEW

PROSPECTIVE DRUG UTILIZATION REVIEW (ProDUR):

Prospective Drug Utilization Review (ProDUR) encompasses the detection, evaluation, and counseling components of pre-dispensing drug therapy screening. The ProDUR

24


system of Affiliated Computer Services assists the pharmacist in these functions by addressing situations in which potential drug problems may exist. ProDUR performed prior to dispensing helps pharmacists ensure that their patients receive appropriate medications. This is accomplished by providing information to the dispensing pharmacist that may NOT have been previously available.

ACS will ensure that the system alerts the pharmacist regarding each specific patient at the time a prescription is being filled of any evidence documenting, but not limited to, suspected drug over utilization, prescription underutilization, duplicate therapy, drug to diagnosis contraindication, drug to drug interaction, drug-age contraindication, drug - pregnancy contraindication and excessive utilization, iatrogenic effects, adverse reactions or treatment failures.

Because Affiliated Computer Services’ ProDUR system examines claims from all participating pharmacies, drugs that interact or are affected by previously dispensed medications can be detected. AFFILIATED COMPUTER SERVICES, INC. recognizes that the pharmacist uses his/her education and professional judgment in all aspects of dispensing. ProDUR is offered as an informational tool to aid the pharmacist in performing his/her professional duties.

Therapeutic Problems:

Maryland Medicaid, BCCDT, KDP and MADAP will deny for Therapeutic Duplication

(TD), the Acute to Maintenance Anti-

Ulcer protocol (PP), and Early Refill (ER) only.

Alert messages will be returned for other ProDUR problem types.

Additional ProDur edit denials may be implemented after April 16, 2003.

Therapeutic Duplication (TD) and Plan Protocol (PP, the Acute to Maintenance Anti-

Ulcer Edit)

ProDUR edits that deny may be overridden by the pharmacy provider at POS using the interactive

NCPDP DUR override codes for selected conflict types.

To request an Early Refill override, contact AFFILIATED COMPUTER SERVICES,

INC.(Maryland Medical Assistance 800-884-3238)(KDP 800-884-7387). See Edits section.

ProDUR denial edits will apply to all media types.

Days Supply:

Days supply information is critical to the edit functions of the ProDUR system.

Submitting incorrect days supply information in the days supply field can cause false

ProDUR messages or claim denial for that particular claim or for drug claims that are submitted in the future.

Technical Call Center:

Affiliated Computer Services’ Technical Call Center is available 24 hours per day, seven days per week.

25


The telephone number is: 1-800-932-3918

Alert message information is available from the Call Center after the message appears. If you need assistance with any alert or denial messages, it is important to contact the Call

Center about Affiliated Computer Services’ ProDUR messages at the time of dispensing.

The Call Center can provide claims information on all error messages which are sent by the ProDUR system. This information includes: NDCs and drug names of the affected drugs, dates of service, whether the calling pharmacy is the dispensing pharmacy of the conflicting drug, and days supply.

The Technical Call Center is not intended to be used as a clinical consulting service and cannot replace or supplement the professional judgment of the dispensing pharmacist.

AFFILIATED COMPUTER SERVICES, INC has used reasonable care to accurately compile ProDUR information. Because this information is unique, this information is intended for pharmacists to use at their own discretion in the drug therapy management of their patients.

Affiliated Computer Services’ ProDUR is an integral part of the Maryland Medical

Assistance Pharmacy Program’s claims adjudication process. ProDUR includes: reviewing claims for therapeutic appropriateness before the medication is dispensed, reviewing the available medical history, focusing on those patients at the highest severity of risk for harmful outcome, and intervening and/or counseling when appropriate.

Coordinated ProDUR:

Coordinated ProDUR (CPD) provides a mechanism to link all of a recipient’s pharmacy history, regardless of payer, for purposes of performing ProDUR. This includes all:

MCO Services

Specialty Mental Health Services

Medical Assistance Program Services

Providers will submit a single transmission only.

Coordinated ProDUR editing is “message only” (i.e. no denials).

ACS will process claims for the Mental Health Carve-out drugs then send any drugs that are denied to the MCO for processing. All claims MUST be sent to the following:

PCN:

BIN: 610084

Group ID’s

I will get these and insert them then resend.

26


Program Specific Information

I

Copays

Maryland Medicaid

Fee for Service = $1.00 / 3.00

(Recipient groups are identified in pharmacy plans 100, 110, 200-299)

PAC copays = $2.50 / 7.50

(Plans # 120, 160, 300-399)

NH = NO copays;

Preg =NO copays (PA type = 4)

Family Planning medications = no copay

(Plan # 130)

MMI State Funded Foster copay = $1.00 / 3.00 (no exceptions)

(Coverage Code = 110.)

MCO/ HMO copay = $1.00 / 3.00

(Plan 200-299)

Copay exceptions ($0 copay) regardless of plan assignment:

Patient <21 years old (as determined by the eligibility file).

Patient is pregnant (as determined by submitting pharmacist entering ‘4’ in Prior Auth

Type Code field.

Drug is a Family Planning drug.

LTC claims, with the exception of groups S16, S17, and S18.

Group S12 and drug is family planning.

PDL – 3 day emergency supply.

Maximum Dollar Amounts :

The system will allow a max cost per prescription of $2500.00 including compounds.

The system will deny claims that exceed the maximum dollar limit of $2500.00 with error 78 (Cost Exceeds Max) and the message text “Contact ACS at 1-800-932-3918 to request override”.

The ACS Technical Call Center may allow prior authorization requests for dollar limit overrides after validating the quantity submitted.

Note: When reviewing submitted claims over $2,500.00, ACS Technical Call Center

27


personnel will consider the following minimal criteria:



Proper dispensing units are being submitted, as per the ACS System editing criteria;



Proper days supply being submitted as per number of units dispensed;



Proper FDA dosing guidelines being followed; and



Quantity limitations that already exist as system edits..

The reviewer will use professional judgment and the above minimal criteria to preauthorize a claim. Claims not in compliance with profession judgment and minimal criteria will be denied.

Days Supply

The system will ensure up to a 34 day supply is allowed for non-maintenance medications and a 100-day supply for maintenance medications. Exceptions:

1.

Oral contraceptives = 180 day supply

2.

14 day supply, as identified through drug file analysis (see below)

3.


4.

90 day supply as identified through drug file analysis (see below)

5.


6.


7.


Max Days 14

Max Days 14 NCPDP 76- Plan Limitations Exceeded /For PA, Call ACS at 1-800-932-3918

HSN = 011796 Helidac

Max Days 28


HSN = 004834 Clozaril (clozapine)

Max Days 90


GSN 017584. Depo-Provera CCM FH015 – status is pending.

Max Days 100

Max Days 100 NCPDP 76- Plan Limitations Exceeded (includes Maintenance Medications) /For

PA, call ACS at 1-800-932-3918. Note: When AHFS codes are used, all sub classifications beginning with the digits specified are included.

28


DEA = 2

GSN = 004964, 044980

DCC = R

AHFS = 24:04

AHFS = 24:06

AHFS = 24:08

AHFS = 24:12

AHFS = 24:12.08

AHFS = 24:16

AHFS = 24:20

AHFS = 24:24

AHFS = 24:28

AHFS = 24:32

AHFS = 28:12:12

AHFS = 28:12:16

AHFS = 28:12:92

HIC3 = C1D

AHFS = 40:28

AHFS = 56:24

AHFS = 68:16

AHFS = 68:20

AHFS = 68:20.08

AHFS = 68:20.20

AHFS = 68:22

AHFS = 68:24

AHFS = 68:32

AHFS = 68:36

All Schedule II Narcotics

Leuprolide 3-month kit

Insulin Syringes

Cardiac Drugs

Antilipemic Agents

Hypotensive agents

Vasodilating agents

Vasodilating Agents

Sclerosin Agents

Alpha-adrenergic blocking agents

Beta-adrenergic blocking agents

Calcium channel blocking agents

Renin-angiotensinaldosterone system inhibitors

Hydantoins

Oxazolidinediones

Anticonvulsants miscellaneous

AHFS 40:12 (Replacement

Solutions)

Potassium supplements only

Diuretics

Lipotropic agents

Estrogens and antiestrogens

Antidiabetic agents

Insulins

Sulfonylureas

Antihypoglycemic agents

Parathyroid

Progestins

Thyroid and Antithyroid agents

29


Listed products only

AHFS = 68:36.04

AHFS = 88:00

HSN = 001879, 001878,

001877



HSN = 000739; and



Route = oral



HIC3 = C3B; or HSN = 001025,

001029, 006485, 001024,

001095, 001086; and

Dosage Form = TC

AHFS = 24:20

AHFS = 24:24

AHFS = 24:28

AHFS = 24:32

AHFS = 24:32.04

AHFS = 24:32.08

AHFS = 88:08:00

AHFS = 88:28:00

GSN 026098

GSN 017584

Thyroid Agents

Vitamins

AHFS 28:12.12

(Hydantoins)

Phenytoin

Phenytoin Sodium

AHFS 20:04.04 (Iron preparations)

Oral products in which ferrous sulfate is the only active ingredient

Chewable tablets of any ferrous salt when combined with vitamin C, multivits, multivits + minerals, or other minerals in the formulation

Alpha-Adrenergic Blocking

Agents

Beta-Adrenergic Blocking

Agents

Calcium-Channel Blocking

Agents

Renin-Angiotensin System

Inhibitors

Angiotensin-Converting

Enzyme Inhibitors

Angiotensin II Receptor

Antagonists

Vitamin B Complex

Multivitamin Preparations

Depo-Provera

Contraceptive 150mg/ml

Disposable Syringe

Depo-Provera

Contraceptive 150mg/ml

Vial

Legend products only



Note: OTC is not a requirement for these chewable Fe products

(per regs)

Max Days 120

Max Days 120 NCPDP 76- Plan Limitations Exceeded/For PA, Call ACS at 1-800-932-3918

30


GSN = 2605, 2607, 2615,

2616, 2617, 2618, 2619, 2621,

2622, 2623, 13383, 16025,

18743, 23716, 24145, 41627

GSN = 044968, 058789

Sodium Fluoride

Leuprolide 4 month kit

Max Days 180

Max Days 180 NCPDP 76- Plan Limitations Exceeded/For PA, Call ACS at 1-800-932-3918

DCC = C

TC = 36

Contraceptives, Oral

Systemic Contraceptives

Claims that deny for exceeding the max day limit will return edit 76 (plan limitations exceeded) and the message text: Max Daily Limit Exceeded/For PA, call DHMH at 1-

410-767-1755

Requests to override Days Supply are directed to Maryland OOEP at (410) 767-1755.

Providers will have the ability to override Days Supply Limits and/or PA Required conditions by entering a value of ‘5’ (exemption from prescription limits) in the Prior

Auth Type Code field (NCPDP field # 416-DG). Note:

1.

This override situation applies to TPL processing only

2.

A value of 5 in the Prior Auth Type Code field is valid only if Other

Coverage Code = 2 (other coverage exists-payment collected)

3.

A value of 8 in the Prior Auth Type Code field is valid only if recipient is pregnant (this will override both coverage limitations and copay)

Prior Authorization

There are four methods a provider can receive a Prior Authorization for Maryland (OOEP)

Medicaid recipients:



ACS Technical Call Center



Maryland Medicaid Staff



CAMP office



SmartPA

To help the provider determine which method they need to use to obtain a Prior

31


Authorization the following messages will be sent back on a claim response:



PA denials will be handled by ACS and will return the following message text in the response: “Prior Authorization Required, Call

ACS at 1-800-932-3918 (24/7/365)”.



PA denials handled by the State will return the following message text in the response:

”Prior Authorization Required, Call MD/ MCOA at (410) 767-

1755, M-F, 8:30 am – 4:30 pm”.



ACS will ensure that PA denials handled by the State's CAMP

Office will return the following message text in the response:

“Prior Authorization Required, call CAMP Office, (410) 706-

3431”.

Below is a list of drugs that require Prior Authorization and which office handles the

Prior Authorization request:

The Maryland Pharmacy Program staff:

All Days Supply

Growth Hormones

Synagis (Palivizumab)

Female Hormones for a male and vice versa

Nutritional supplements (see MD PA form for clinical criteria)

Recipient Lock-In

Price (long-term PAs only)

Oxycontin Quantity (during business hours)

Antihemophilic Drugs (claim pended in X2 and evaluated manually by State) -Duragesic

Patch Quantity (during business hours)

Topical Vitamin A Derivatives

Opiate Agonists for Hospice and Hospice/LTC

Antiemetic

Serostim

Botox

Orfadin

Revlimid

Revatio

Brand Medically Necessary

The ACS PA Call Center :

Quantity (Note Oxycontin, Duragesic Patch exceptions)

1.

CNS Stimulants

32


2.

Actiq

3.

Anti-Migraine

4.

Anti-Psychotics

5.

Oxycontin, Duragesic Patch Qty for after hours/weekends

Maryland Pharmacy Programs Camp Office:

1.

Depo Provera

2.

Lupron Depot

ACS Technical Call Center:

1.

PDL - Non-Preferred drugs

2.

Early Refill

3.

Maximum dollar limit per claim = $2500.

4.

Age Restrictions – Administered by X2

5.

Max Quantity overrides – Administered via X2

SmartPA

SmartPA is an automated, rules engine, driven system that uses both the medical and pharmacy information to either grant a Prior Authorization or deny based on the rules for that particular drug being dispensed. If criteria are met upon claims submission, no call for PA will be required. The system will automatically generate a Prior Authorization and the claim will pay. When a claim is denied by SmartPA, the exception message will state which criteria was not met in order for the PA to be issued. The ACS Technical

Call Center will handle any Prior Authorization questions based on a SmartPA denial.

Below is a list of drugs / categories that will be handled by SmartPA:

1.

CNS Stimulants

2.

Actiq

3.

Anti-Migraine

4.

Atypical Antipsychotics

5.

Serostim

6.

Botox

7.

Synagis

8.

Growth Hormones

9.

Antiemetics

33


10.

Topical Vitamin A

11.

Orfadin

12.

Revlamid

13.

Revatio

14.

Nutritional Supplements

15.

Oxycodone

Coordinated ProDur / Mental Health Formulary

Coordinated ProDUR:

Coordinated ProDUR (CPD) provides a mechanism to link all of a recipient’s pharmacy history, regardless of payer, for purposes of performing ProDUR. This includes all:

34




MCO Services



Specialty Mental Health Services



Medical Assistance Program Services



Providers will submit a single transmission only.

 Coordinated ProDUR editing is “message only” (i.e. no denials).

The ACS POS system has a mechanism, which at the pharmacy level, with one transmission, will electronically link the payer with all recipient drug information necessary to perform Coordinated PRO-DUR. This requires any payer (MCO or MA) to have available at the time of adjudication all recipient drug history including but not limited to somatic, psychotropic, and specified HIV drug paid claims information to perform a comprehensive PRO-DUR, eliminating the need for the pharmacy provider to make multiple entries into different networks. Regardless of the final payer, only one transmission fee, which includes switching cost, is to be paid by pharmacy providers adjudicating claims through this program.

ACS will process claims for the Mental Health Carve-out drugs then send any drug that are denied to the MCO for processing. All claims MUST be sent to the following:

PCN:

BIN: 610084

Group ID’s

I will get these and insert them then resend.

Mental Health Formulary

All Mental Health claims will be processed through the MD/ MA POS system

The following table includes mental health drugs that are carved out of the Managed Care

Organization (MCO) pharmacy benefit.

All drugs from American Society of Health-System Pharmacists (AHFS) therapeutic classes included in this table, including specific drugs that may not be listed in this table, are carved out of the MCO pharmacy benefit and are payable as fee-for-service through

Maryland Medical Assistance with the following exceptions.

The following seven drugs, which may be used for some mental health indications, are not payable fee-for-service (unless otherwise noted) and are the responsibility of the

HealthChoice MCOs for their enrollees, regardless of the prescriber.

35


Leuprolide acetate

+

Naltrexone Liothyronine

Clonidine

Guanfacine

Medroxyprogesterone

+

Disulfiram

+

When used to treat males for behavioral problems, will be paid fee-for-service, but will require pre-authorization (PA).

There are also six drugs included in the table below that have been bolded and marked with an “*”. These drugs are also exceptions to the carve-out and must be covered by the

MCOs.

Please note: All brand drugs, which are available as multi-source generics, require prior approval and completion of a Maryland Medwatch Form unless otherwise noted.

Therapeutic Class

Antiparkinsonian Agents

AHFS Class No. 120804

Miscellaneous Anticonvulsants


Antidepressants


Drug benztropine biperiden procyclidine trihexyphenidyl carbamazepine * gabapentin *

Gabitril

Keppra

Lamictal *

Lyrica

Tegretol XR (PA)

Trileptal

Topamax * valproate/divalproex

Zonegran amitriptyline amoxapine bupropion bupropion SR citalopram clomipramine

Cymbalta desipramine doxepin

36


Antipsychotic Agents


Abilify

chlorpromazine clozapine

FazaClo fluphenazine

Geodon

haloperidol loxapine

Moban

37


Effexor XR

Emsam fluoxetine fluvoxamine imipramine

Lexapro

Maprotiline

Marplan mirtazapine mirtazapine Soltab

Nardil nefazodone (PA) nortriptyline

Parnate paroxetine

Paxil CR

Pexeva protriptyline

Prozac Weekly (PA)

Sarafem (PA) sertraline (PA)

Surmontil

Symbyax (PA) trazodone

Wellbutrin XL venlafaxine

Orap perphenazine

Risperdal

Risperdal M-Tab

Seroquel

Symbyax thioridazine thiothixene trifluoperazine

Zyprexa

Zyprexa Zydis

Anorexigenic Agents and

Respiratory and Cerebral

Stimulants


Adderall XR (over age 12 PA required) amphetamine (over age 12 PA required)

Concerta

Desoxyn (PA) dextroamphetamine (over age 12 PA required)

Focalin

Focalin XR

Metadate CD methamphetamine (over age 12 PA required) methylphenidate pemoline (PA)

Provigil (PA)

Anxiolytics, Sedatives and

Hypnotics – Benzodiazepines


Ritalin LA

(PA)

Strattera (Step therapy required age 17 and under) alprazolam chlordiazepoxide clorazepate

Diastat diazepam

Doral (PA)

38


estazolam flurazepam lorazepam midazolam* oxazepam

Restoril 7.5mg (PA)

Restoril 22.5mg

(PA) temazepam triazolam clonazepam Benzodiazepines


Miscellaneous Anxiolytics,

Sedatives and Hypnotics


Ambien

Ambien CR buspirone chloral hydrate droperidol* hydroxyzine

Lunesta (PA)

Meprobamate

Rozerem

Sonata lithium Antimanic Agents


PA = Prior authorization required

MH Drug Restrictions

Recipient Status

Drug Recipient

Sex

Fee for Service Mental Health N/A

Disposition

Non-MH N/A

Depo-

Provera,

150mg

Depo-

Provera,

150mg

F

M

39


Continue processing, all edits apply

Continue processing, all edits apply

Continue processing (PA not required)

DENY, “PA Required,

Call 410-706-3431”

Payer

FFS

FFS

FFS

FFS

Recipient Status

Drug

Depo-

Provera,

400mg

Depo-

Provera,

400mg

Lupron

Depot, 7.5mg

Recipient

Sex

F

M

Disposition

Continue processing (PA not required), all edits apply


Call 410-706-3431”

Lupron

Depot, 7.5mg

Lupron

Depot,

22.5mg

Lupron

Depot,

22.5mg

Lupron

Depot, all other strengths

Lupron


Clozaril

F

M

F

M

F

M



Call 410-706-3431”



Call 410-706-3431”



N/A Continue processing (PA not required), all edits apply

Disposition Recipient Status Drug

MCO

Recipient

Sex

Mental Health N/A Continue processing, all edits apply

Non-MH

Depo-

Provera,

150mg

Depo-

Provera,

N/A

F

DENY, “Bill MCO”


M

40



Call 410-706-3431”

Payer

FFS

FFS

FFS

FFS

FFS

FFS

FFS

FFS

FFS

Payer

FFS

MCO

MCO

FFS

Recipient Status

Drug

150mg

Depo-

Provera,

400mg

Depo-

Provera,

400mg

Lupron

Depot, 7.5mg

Lupron

Depot, 7.5mg

Lupron

Depot,

22.5mg

Lupron

Depot,

22.5mg

Lupron


Lupron


Clozaril

Recipient

Sex

F

M

F

M

F

M

F

M

41


Disposition


Call 410-706-3431”


Call 410-706-3431”



Call 410-706-3431”



Call 410-706-3431”



Payer

FFS

FFS

MCO

FFS

MCO

FFS

MCO

MCO

FFS

Age Limitations :

Maryland Medicaid will enforce the following Age Restrictions: a.

Non-legend chewable tablets of any ferrous salt when combined with vitamin C, multivitamins, multivitamins and minerals, or other minerals in the formulation: b.

1.

Covered for age <12 years

2.

Claims for age >/= 12 will deny (not covered)

Topical Vitamin A Derivatives, HIC3 = L9B; and Route = Topical

(e.g., Retin-A)

1.

Covered for age < 60 years.· PA required >/= 60

2.

Otherwise, NCPDP 60 and message text: "Product/Service Not

Covered for Patient Age - Call DHMH at 1-410-767-1755", MD will handle PA requests. c. Ferrous sulfate covered for recipients < 12 years. Otherwise, NCPDP 60 and message text: "Product/Service Not Covered for Patient Age” &/or

NCPDP 76 and message text: Plan Limitations Exceeded – Call DHMH at

1-410-767-1755":

This rule pertains to non-legend chewable tablets of any ferrous salt when combined with vitamin C, multivitamins, multivitamins and minerals, or other minerals in the formulation, HIC3 = C3B; or HSN = 001025,

001029, 006485, 001024, 001095, 001086; and Dosage Form = TC; and

OTC. Minimum quantity per fill = 60 tabs.

42


LTC / Hospice Claim Billing

The system will determine Hospice-Only claims by the following conditions:

1.

Claim contains Patient Location code = ‘11’ (NCPDP field 307-C7)

2.

Client Specific Reporting field on Recipient Eligibility file = "HI"

3.

The Date of Service is within an active coverage span on the

Recipient Eligibility file

4.

Facility ID (NCPDP field # 336-8C) is on list of institutions (see appendix OOEP-14)

Note: The system will deny Hospice claims that do not have both a

Patient Location code = ‘11’ and a Client Specific Reporting field on

Recipient Eligibility file = "HI.

The system will determine LTC claims by the following conditions:

1.

Claim contains Patient Location code = ‘04’ (NCPDP field 307-C7)

2.

Facility ID (NCPDP field # 336-8C) is on list of institutions (see appendix OOEP-14)

3.

Pharmacy Provider ID is on the list of LTC providers (see appendix

OOEP-15)

Note: Existing "NH" provider numbers = LTC providers / institutions

ACS will determine RECIPIENTS with BOTH LTC/HOSPICE

LTC/Hospice claims will be determined by the following distinct conditions:

1.

Client SPECIFIC REPORTING field = "HI" on the recipient's

43


enrollment record with a date span that includes DOS, AND

2.

PATIENT LOCATION (NCPDP field # 307-C7) = "11", AND

3.

FACILITY ID (NCPDP field # 336-8C) any value on the list of institutions, AND

4.

Designated LTC providers in the SERVICE PROVIDER ID

(NCPDP field # 201-B1)

The system will deny non-LTC claims for unit dose medications with the exception of drugs in appendix OOEP-8; claims will deny with error 70 (drug not covered) and message text: “Unit Dose Package Size

Emergency Fill

The system will allow emergency fills when claims contain a ‘3’ in the Level of Service field (emergency).

1.

Pharmacy Program recipients will be allowed two 72-hour emergency fills per Rx (no dispensing fee on second emergency refill) for non-PDL drugs except for those medications listed in

Appendix OOEP-20. These medications are not limited to a 72hour supply.

2.

Nursing Home recipients will be allowed a 30 days supply of non-

PDL drugs

3.

Generic Mandatory

The system will deny brand drugs when a generic is available with edit 22 (M/I /DAW code) and the message text: “Generic Available – Call State at 410-767-1755, MedWatch form required” when submitted as Brand Medically Necessary (DAW = 1) with the exception of the following (pay at EAC):

Levothyroxine HICL seq Num = 002849

Brimonidine eye drops GSN = 48333 and 27882

The system will cover brand drugs billed as generic with DAW=5 without preauthorization Brand drugs will be rejected with NCPDP edit 22 (M/I DAW code) and the message text: “Generic Available – Call State at 410-767-1755, MedWatch form

The system will accept the following Dispense as Written (DAW) values (NCPDP field

408-D8):

44


0 - default, no product selection

1 - Physician request

5 - Brand used as generic

6 – Override

Pricing

Reimbursement for Maryland Medicaid claims will follow the structure listed below:

1) Legend Drugs, Schedule V Cough Preps, Enteric Coated Aspirin, Oral Ferrous

Sulfate Prods

Payment is Lesser of:

U/C -or- Allowable Cost + Dispensing Fee

Allowable Cost lesser of:

1. IDC,

2. EAC (lesser of): WAC+8%· Direct+8%· · AWP - 12%,

3. FUL

2) Chewable Ferrous Sulfate with Multivitamins


U/C -or- Allowable Cost + 50% -or- Allowable Cost + Dispensing Fee

Allowable Cost is lesser of:

1. IDC

2. EAC (lesser of): WAC+8% -or- Direct+8% -or- AWP - 12%

3. FUL

3) Condoms


45


U/C -or- Allowable Cost + 50%

Allowable Cost:

EAC (lesser of): WAC+8% -or- Direct+8% -or- AWP – 12%

4) Home IV Claims – Claims will be available for State re-pricing through a process developed by ACS and approved by the State.

5) Medical Supplies and Durable Medical Equip (Needles and Syringes )



Allowable Cost: AWP

6) DAW 1 and 6 Claims



Allowable Cost:

EAC (lesser of): · WAC+8% -or- Direct+8% -or- AWP – 12%

7) Other OTC Drugs (Insulin and Nutritional Supplements)


U/C -or- Allowable Cost + 50% -or- Allowable Cost + Dispensing Fee

Allowable Cost: AWP

Dispensing fees

:

Brand not on PDL : $2.69;

PDL and generic: $3.69

NH :

1.

Brand not on PDL = $3.69;

2.

PDL and generic: $4.69

* limit of 1 dispensing fee/month /NDC for NH patient: (can be overridden by PA type code = 5).

LTC Dispensing Fee :

1.

Brand name drug not on PDL - $3.69

2.

Generic drug or brand name drug on PDL $4.69

46


Hospice Dispensing Fee:

1.

Brand name drug not on PDL - $3.69·

2.

Generic drug or brand name drug on PDL - $4.69

LTC/Hospice Dispensing Fee

1.

Brand name drug not on PDL - $3.69·

2.

Generic drug or brand name drug on PDL - $4.69

Partial Fills :

1.

½ dispensing fee at initial fill

2.

½ dispensing fee at completion fill

3.

Copay paid on initial fill.

Drug Coverage

ACS will ensure that all drugs in Therapeutic Classes 01-99 are covered, except where exclusions are noted in this section below.

The following rules will be enforced for OTC Drugs

1.

Generally not covered, (note exceptions in Drug List appendix OOEP-7).

2.

Covered OTC drugs must be rebateable. Non-rebateable drugs will deny,

NCPDP 70, ‘NDC Not Covered’. Note: MD staff will have the ability to override these denials for exceptional cases (not routine), calls should be referred to the DHMH PA Unit.

The following rules apply to DME/DMS :

1.

Needles and syringes are covered through POS.

2.

All other DME/ DMS (durable medical equipment/ disposable medical supplies) should be billed on a HCFA 1500 form and forwarded to the DME/ DMS Unit.

3.

Questions should be addressed to the Program Specialist at DME/

47


DMS at (410) 767-1739.

The following are exceptions to the rules for DME/DMS:

1.

Needles & Syringes, Drug Category = M, N, O, P, Q, R

2.

Pen Needles, HSN = 008966

ACS will ensure that LTC Drug Coverage Exceptions include:

1.

OTC (including needles, syringes, and nutritional supplements) are not covered except for insulin and Schedule V cough preps.

2.

All normally covered medications in Unit Dose form

3.

Hospice Drug Coverage exclusions include:

AHFS = 28:08.08

This will be denied with edit 75, PA required and the message: “Bill Hospice –

Call State with any questions”. State staff will handle override approvals.

ACS will ensure that LTC/Hospice:

1.

Covers all unit dose items

2.

Coverage exclusions: OTC (including needle, syringes, & nutritional supplements

3.

Coverage exclusions: AHFS = 28:08.08. will be denied with edit 75,

PA required and the message: “Bill Hospice – Call State with any questions”. State staff will handle override approvals.

Unit Dose:

The system will deny unit dose drugs with edit 70 (drug not covered) with the exception of drugs listed in appendix OOEP-8. Message text to providers: “Unit Dose Package”.

Package Size:

The system will ensure that products commonly billed with incorrect quantity (i.e.:

Opthalmics, prefilled injectable syringes, etc.) are submitted in multiples of correct package size, otherwise claims will be denied for missing/invalid quantity.

48


The following are covered under family planning:

1.

Drug Category = C, T - Contraceptives, Oral & Topical

2.

TC = 63 - Systemic Contraceptives

The following gender specific coverage will be enforced and deny with edit 70, Female only:

1.

Drug Category C - contraceptives, oral

2.

HIC3: X1B - Diaphragms/Cervical Cap

3.

Drug Category = W, except Depo-Provera: GSN = 017584, 026098,

003268, 003270, Contraceptives, Systemic, non-oral

Note: The Depo-Provera exceptions are listed here because this drug denies for ‘PA

Required’ for males, thus NCPDP 70 is not the appropriate error. – Remove gender requirement.

COMPOUNDED HOME INFUSION (HOME IV) CLAIMS:We need to verify if this is still true….



Provider will enter actual NDC of each ingredient (one claim for each ingredient).

 Provider will submit ‘99’ in the Submission Clarification Code field (NCPDP field

#420-D) to indicate this is a Home IV claim.

 Claims will deny with NCPDP Error Code 70, ‘Submit Home IV Claim to State’.

Submit the claim to Maryland Medical Assistance using the standard Invoice for all IV

Compounds form which can be downloaded from http:/mdmedicaidrx.fhsc.com.



Maryland Medical Assistance will review the claim and either approve or deny. If approved the claim will be manually priced and payment released.



Expected reimbursement for each claim must be submitted in the GROSS AMOUNT

DUE field (NCPDP field # 430-DU).



Include the expected reimbursement for the supplies and compounding materials with the diluent claim. For the TPN claim, the diluent is the water for injection.



Providers must bill the NDC of one diluent only.



Use decimal quantities, do not round up.

49


 Include prescription numbers for all ingredient claims used on the “Standard Invoice for all IV Compounds”.



Provide a copy of the prescriber’s order

MEDICARE RECIPIENTS:

QMB (Qualified Medicare Beneficiaries):



There are no special processing requirements for QMB recipients (coverage group

S03).



The system will deny claims for QMB recipients (coverage group S03, S06, S07, S14,

S15, D01, D03) with error 70 (NDC not covered) and message text: “No Rx Coverage for

Group”.

Medicare Part B:

 If a recipient has Medicare Part B coverage (as defined by ‘Secondary’ on the patient enrollment record), in addition to MA coverage, drugs on this list will deny and require billing to Medicare. The provider must bill Medicare to determine the reimbursement amount. If the recipient is in Pharmacy Assistance Program, the provider may bill

Maryland Medical Assistance with the actual Medicare payment amount in the TPL field.

If the recipient is in a group other than Pharmacy Assistance

Program and the claim is submitted as secondary to Maryland Medicaid, the claim will deny.



If Medicare does not cover the drug (e.g., diagnosis not approved), providers should contact the Affiliated Computer Services’ Technical Call Center for a PA.

 If a recipient is in group S16, S17 or S18 (Maryland Pharmacy Program) and has

Medicare Part B coverage (as defined by ‘Secondary’ on the patient enrollment record), the drugs on this list will deny for NCPDP 70 – Drug Not Covered with the additional message “Collect Patient Share”. Once the pharmacy has billed Medicare and obtained the amount paid by Medicare, the provider may bill MARYLAND with the actual amount Medicare has paid in the TPL field. The claim will function as any other TPL claim; reimbursement will be based on the “lesser of” logic, taking the TPL amount into consideration. The 65% copayment will be assessed on the final payment amount and subtracted from the amount to be paid to the pharmacy. The pharmacy should NOT enter payments collected from recipients in the PATIENT PAID field when submitting the claim as this would cause the recipient additional copayments and also reduce payments to the pharmacies by the amount submitted in the PATIENT PAID field .

Medicare Covered Drugs - NCPDP 70- NDC Not Covered, Bill Medicare. Providers will contact ACS Call center for PA if not covered by Medicare.

Medicare D:

50


The following rules will be implemented for MED D:

1.

OOEP will not be processing COB claims for part D eligible patients

2.

Denied claims for Part D covered products will return a NCPDP 41 –

Submit Bill to Other Processor or Primary Payer

3.

See appendix OOEP-5 for a list of Medicare Part D Excluded Drugs that are covered by OOEP.

Breast and Cervical Cancer Diagnosis and Treatment (BCCDT)

Refills



A maximum of 11 refills for Non-Controlled Covered Drugs.



Refills are not allowed on non-controlled drugs to be filled 360 days or more from the date prescribed.



A maximum of 5 refills for Schedules III, IV and V controlled covered drugs.



Refills are not allowed on controlled drug to be filled 180 days or more from the date prescribed.

51


The system will not allow refills for Schedule II controlled covered drugs

Pricing

ACS will ensure the claims reimburse at the following pricing:

Lesser of :

- U & C

- Allowable Cost + dispensing fee

Allowable Cost:

Lesser of:

1. IDC

2. EAC (lesser of): WAC+8%· Direct+8%· AWP - 12%

3. FUL

Copays :

There are no copays for BCCDT recipients

Dispensing Fee:

BCCDT has the following dispensing fee structure:



BRAND products = $2.69



Generic Products = $3.69

 Partial Fill dispensing fee will be paid ½ at the initial fill and ½ at the completion fill

Prior Authorization

Prior Authorization requests will be handled either by the BCCDT office or at the ACS

Technical Call Center. Below is a list of drugs that are handled by each entity:

ACS Technical Call Center

The ACS Call Center will handle the following prior authorization requests on behalf of MD BCCDT:

1. Brand Medically Necessary - DAW 1, with exceptions

2. Day Supply for approved situations

52


PA denials handled by ACS will return the following message text in the response: “Prior

Authorization Required, Call ACS at 1-800-932-3918 (24/7/365)”.

BCCDT Office

The MD BCCDT staff will handle the following prior authorization requests:

1.

Early Refill - For requests outside established criteria

2.

PA/Medical Certification - authorization based on diagnosis

3.

DME/DMS for HCFA 1500 billing - exception: needles, syringes that are paid through POS

PA denials handled by MD BCCDT will return the following message text in the response: “Prior Authorization Required, call MD BCCDT (410) 767-6787, M-F, 8:30 am – 4:30 pm”.

Drug Coverage

Drug Coverage is defined by the BCCDT program and its parameters. Below is a grid of covered drugs for all groups active on the Date of Service (DOS) with BCCDT:

S2B

W1W

W1X

W1Y

W1Z

W1K

W1D

W2F

H2E

Drug Code

H3A

H3D

H3E

H6J

Drug Name

Analgesics, Narcotics

Analgesics, Salicylates

Analgesics/Antipyretics, Non-

Salicylates

Anti-emetics

Comments

Oral forms only covered


Anti-Inflammatory Agents

Cephalosporins – 1 st

gen

Cephalosporins – 2 nd

gen

Cephalosporins – 3 rd gen

Cephalosporins – 4 th

gen

Lincosamides

Exclude HSN 002005 –

Scopoloamine







Macrolides

Nitrofuran Derivatives



Non-Barbiturates, Sedative-Hypnotic Oral forms only covered

53


W1A

W1Q

H7E

H7C

H2S

W1C

W4E

H2U

HSN 010249

HSN 001653

HSN 018385

HSN 002860

HSN 003893

HSN 002889

HSN 001847

HSN 020803

GSN 011832, 001645, 001646,

017378

HSN 002867

HSN 012351

HSN 001975

HSN 002877

HSN 002148

HSN 004129

HSN 002874

HSN 002879

HSN 012014

HSN 011632

HSN 018801

HSN 33401

HSN 02045

HSN 01608

HSN 11506

HSN 21157

F1A

TC 48

D6D

Z2A

TC 30

TC 16

Penicillins

Quinolones

Serot-2 Amtag/Reuptake Inhib

(SARIS)

Serot-Norepineph Reup-Inhib

(SNRIS)

Serotonin Spec Reuptake Inhib

(SSRI)

Tetracyclines

Trichomonacides

Tricy Antidepr & Rel NSRUI

Anastrozole

Bupropion HCL

Capecitabine

Cortisone Acetate

Cyclophosphamide

Dexamethasone

Deflunisal

Exemestane

Ferrous Sulfate

Hydrocortisone

Letrozole

Meclizine HCL

Methylprednisolone

Metoclopramide HCL

Nystatin

Prednisolone

Prednisone

Promethazine HCL

Toremifene Citrate

Trastuzumab

Biafine Emulsion

Dicyclomine

Hydroxyzine

Mirtazepine

Zyvox

Androgenic Agents

Anticonvulsants

Anti-diarrheal Agents

Antihistamines

Antineoplastic Agents

Antitussives – Expectorants

54










Exclude GSN 031439

OTC TO COVER

Rectal forms only covered

TC 15

TC 76

P5A

TC 58

TC 74

TC 79

Q6I

Q6W

Q6P

Q6V

Q6S

TC 71

D6S

H7J

M9P

C1D

H6H

TC 55

Q5P

Q4F

TC 72

TC 73

HSN 004047

HSN 007708

HSN 009005

HSN 022142

GSN 007062

HSN 015176

GSN 040262

GSN 043256

GSN 003407

GSN 003411

GSN 003412

GSN 007407

GSN 007409

HSN 016196

HSN 003385

HSN 007527

HSN 003363

HSN 004107

55


Bronchodilators

Cardiovascular Preparations, Other

Corticosteroids, Inhaled

Diabetic Therapy

Digitalis Preparations

Diuretics

Eye Antibiotic – Coticoid

Combination

Eye Antibiotics

Eye Antiinflammatory Agent

Eye Antiviral

Eye Sulfonamide

Hypotensive, Others

Laxatives & Cathartics

MAOIS – Non-Selective &

Irreversible

Platelet Aggregation Inhibitors

Potassium Replacement

Skeletal Muscle Relaxants

Thyroid Preparations

Topical Antiinflammatory

(corticosteroids)

Vaginal Antifungals

Vasodilators, Coronary

Vasodilators, Peripheral

Bacitracin

Cadexomer Iodine

Fosfomycin Tromethamine

HC Acetate/Lidocaine HCL

HC Acetate/Pramoxine HCL

Hydrocortisone/Pramoxine HCL

Lidocaine

Lidocaine

Lidocaine HCL

Lidocaine HCL

Lidocaine HCL

Lidocaine HCL

Lidocaine HCL

Lidocaine/Prilocaine

Mupirocin

Mupirocin Calcium

Neomy Sulf/Bacitra/Polymyxin B

Phenazopy HCL/Hyoscy/Butabarb

GSN 009477

GSN 009478

HSN 004284

HSN 004285

HSN 004270

HSN 020355

HSN 004283

W3B

P4B

P4L

D4K

N1B

M9K

N1C

M9L

Q5F

Q4W

Q4S

HSN 003904

HSN 010798

HSN 004570

HSN 010778

HSN 007845

HSN 010166

HSN 025963

HSN 002285

HSN 010280

HSN 003916

HSN 006578

HSN 023523

HSN 021114

HSN 021102

HSN 003923

HSN 003905

HSN 003926

HSN 003912

HSN 003913

HSN 009614

Q4K

HSN 003902

HSN 003907

HSN 004101

56


Phenazopyridine HCL

Phenazopyridine HCL

Sodium CL 0.45PC Irrig. Soln

Sodium CL Irrig Soln

Sodium Hypochlorite

Temozolomide

Water for Irrigation, Sterile

Antifungal Agents

Bone Form, Stim Agents Parathy

Bone Ossification Suppression

Agent

Gastric Acid Secretion Reducers

Hemantinics, Other

Heparin Preparations

Leukocyte (Wbc) Stimulants

Oral Anticoagulants, Coumarin Type

Topical Antifungals

Vaginal Antibiotics

Vaginal Sulfonamides

Carboplatin

Gemcitabine HCL

Ifosfamide

Irinotecan HCL

Melphalan

Paclitaxel, Semi-Synthetic

Bevacizumab

Biafine Cream

Docetaxel

Doxorubicin HCL

Epirubicin

Fulvestrant

Goserelin Acetate

Leuprolide Acetate

Megestrol Acetate

Methotrexate Sodium

Tamoxifen Citrate

Vinblastine

Vincristine Sulfate

Vinorelbine Tartrate

Vaginal Estrogen Preparations

Cisplatin

Fluorouracil

Methanamine Hippurate

HSN 004102

HSN 004094

G1A

HIC3 = C5U

HIC3 = C5F

HIC3 = C1W

HIC3 = C5G

HIC3 = M4B

TC = 68

HSN 004182, 004183

HSN 009007

HSN 010117

HSN 013221

H3N

Methenamine Mandelate

MTH/ME

BLUE/BA/SALICY/ATP/HYOS

Estrogenic Agents

Nutritional Therapy, Med Cond

Special Electrolytes & Misc.

Nutrients

Dietary Supplements

Electrolyte Maintenance

Food Oils

IV Fat Emulsions

Protein Lysates

Acyclovir, Zovirax famcyclovir valacyclovir foscarnet

Narcotic/NSAID

Claims for Gastric Acid Secretion Reducers (D4K) will pay without a PA if the patient is in plans BCCDT1, BCCDT2 or BCCDT4 -and- the patient medication history finds a paid claim within last 34 days for H6J or HSN 002874, 002879, 002889, 002860, and

02867.

ACS will ensure that claims for drug code C1D (Potassium Replacement) are payable if the patient has a paid claim for a drug in TC = 79 (Diuretics) within the last 34 days.

OTC Drug Coverage

OTC drugs are generally not covered by BCCDT but there are exceptions and they are in the grid below:

Oral forms only

Includes products for disease-specific nutritional therapy

Includes Ensure-type products

Includes electrolyte solutions

Includes corn, safflower oils

Includes amino acid products

No PA required

57


OTC Exception List – All OTCs to deny w/ NCPDP 70 – Drug Not Covered w/the exception of the products listed below

Drug Code

HIC3 = C5U

HIC3 = C5F

HIC3 = C1W

HIC3 = C5G

HIC3 = M4B

GSN 011832, 001645, 001646,

017378

Drug Name

Nutritional Therapy, Med Cond

Special Electrolytes & Misc.

Nutrients

Dietary Supplements

Electrolyte Maintenance

Food Oils

IV Fat Emulsions

Ferrous Sulfate

Comments

Includes products for disease-specific nutritional therapy

Includes Ensure-type products

Includes electrolyte solutions

Includes corn, safflower oils

OTC TO COVER

Medicare B:

The system will pay coinsurance for QMB recipients (plan 910) if claims contain an other coverage code of 3 or 4 for Med-B covered drugs only.

ACS will ensure that QMB recipients (plan 910) have pharmacy coverage except for drugs covered by Medicare B such as Xeloda- then BCCDT pays only denied claims.

Pharmacies then must bill Medicare and then Medicaid and BCCDT will be the payer of last resort for coinsurance.

The system will reject QMB claims (plan 910) where the Other Coverage Code is not equal to ‘3-4’; the response will contain reject code edit 70 (Drug Not Covered) and the message text “BCCDT Only Reimburses Non-Covered Medicare B covered drugs"

The system will require claims for COB copay only billing to adhere to the following

NCPDP parameters:

1.

NO COB SEGMENT SUBMITTED

2.

OCC = 8

3.

Other Amount Claimed Qualifier = 99

4.

Other Amount Claimed = Amount of copay

5.

Gross Amount Due = Equal Other Amount Claimed/Amount of copay

6.

No Ingredient Cost or Dispensing fields are expected (however, these could be submitted with zeros). The recommendation allows partners to stay in compliance to the definition of Gross Amount

58


Due.

7.

Other Amount Claimed Submitted must be the entire patient copay as charged by the pharmacy

Description Code Level Code Values

The system will deny COB claims for Medicare B recipients (plan 980) if the Other Coverage Code is not equal to ‘2’ with edit 41 (bill other insurance) and the message text: “Bill Medicare B“.

The following is a list of drugs not covered by Medicare B:

Drug Code

GSN = 008838

GSN = 008770, 008771

GSN = 008773

GSN = 036872, 045266,

035928, 036874, 047823,

047824

HSN = 018385

Oral Chemotherapy

VePesid



(Etoposide)

Cytoxan



(Cyclophosphamide)

Alkeran



(Melphalan)

Methotrexate

Xeloda



(Capecitabine)

Medicare D:

BCCDT will cost avoid for Medicare D recipients. Providers are required to ensure

COB claims for Medicare D to contain “77777” in the Other Payer ID (NCPDP field

340-7C). The Other Payer ID is not required for non-Medicare D carriers.

Below is a list of drugs not covered by Medicare D but covered by BCCDT:

59


Medical Supplies TC 00

Exceptions:

Part D Must Cover

GSN = 009797

HSN = 004348

HSN = 008966

DCC = Q, R

F Agents used for anorexia, weight loss or weight gain

Agents used for symptomatic relief of cough/cold

Rx vitamins and minerals, except prenatal vitamins and fluoride products

OTC

Benzodiazepines:

Alprazolam

Chlordiazepoxide

Clorazepate

Diazepam

Halazepam

Lorazepam

Oxazepam

Prazepam

Estazolam

Flurazepam

Midazolam

Quazepam

Temazepam

Triazolam

Clonazepam

DCC

TC 16

17

TC 80

81

82(Except HIC3=C6F)

83

84

85

Rx Required Field N = OTC Drugs

Exceptions:

Part D Must Cover

HSN

HSN = 011115 & OTC

HSN = 007605 & OTC

& Generic

001617

HSN

HSN

HSN

HSN

HSN

HSN

HSN

HSN

HSN

HSN

HSN

HSN

HSN

HSN

HSN

001611

001610

001612

001615

001618

004846

001616

001613

006036

001593

001619

001595

001592

001594

001894

60


.

Copay Only Claim Submission

BCCDT will allow for the submission of copay only claims but the following rules must be followed in order for the claim to be reimbursed:



There is a $60.00 maximum on all copay only claims. Claims submitted for amounts greater than the maximum will have to be approved by BCCDT.



BCCDT will pay copayments for PAC (plan 930 - formerly MPAP) recipients if claims contain an "8" in NCPDP field 308-C8, Other Coverage Code.



The system will reject PAC claims (plan 930) where the Other Coverage Code is not equal to ‘8’ (Copay Only) with reject code edit 70 (Drug Not Covered) and the message text “BCCDT Only Reimburses Copayments – Please bill PAC



The following fields must be populated when submitting a copay only claim:



Other Coverage Code (308-C8) = 8



Other Amount Claimed Submitted Count = 1



Other Amount Claimed Submitted Qualifier = 99



Other Amount Claimed Submitted = copay amount and must equal the amount in Gross Amount Due



Gross Amount Due = copay amount and must equal the amount in the Other Amount Claimed Submitted

**No COB Segment is submitted with a Copay only claim.

Generic Mandatory

BCCDT has a generic mandatory program in place. The system will deny brand drugs when a generic is available with edit 22 (M/I Dispense As Written/DAW code) when submitted as Brand Medically Necessary (DAW = 1).

The system will accept the following Dispense as Written (DAW) values

(NCPDP field 408-D8):




61


QMB Recipients

The system will pay coinsurance for QMB recipients (plan 910) if claims contain an other coverage code of 3 or 4 for Med-B covered drugs only.

ACS will ensure that QMB recipients (plan 910) have pharmacy coverage except for drugs covered by Medicare B such as Xeloda- then BCCDT pays only denied claims.

Pharmacies then must bill Medicare and then Medicaid and BCCDT will be the payer of last resort for coinsurance.

The system will reject QMB claims (plan 910) where the Other Coverage Code is not equal to ‘3-4’; the response will contain reject code edit 70 (Drug Not Covered) and the message text “BCCDT Only Reimburses Non-Covered Medicare B covered drugs"

Edits and Messaging:

Claims for recipients in all plans, regardless of diagnosis with edit 75 and message text:

PA required, call MD BCCDT 410-767-6787.

Claims for recipients in plan BCCDT1, breast cancer will deny with edit 75 and message text: PA required, call MD BCCDT 410-767-6787.

Claims for drugs for recipients in plan BCCDT2, cervical cancer will deny with edit 75 and message text: PA required, call MD BCCDT 410-767-6787

Claims will deny drugs with edit 75 (PA Required) for recipients in plan BCCDT3

(unknown diagnosis). Provider will receive the message text: Prior Authorization

Required: MD Call 410-767-6787 FOR PA.

Claims that deny for exceeding the max quantity will return edit 76 (plan limitations exceeded) and the message text: max quantity Exceeded - Call BCCDT at (410) 767-

6787.

62


MADAP

The specific Maryland AIDS Diagnosis Assistance Program information is listed in this section. The basic information is covered in the beginning of this manual in the ALL section. In this section you will find some repetitive information but new, special rules as well.

Generic Mandatory

The system will deny brand drugs when a generic is available and the DAW code = 1

(Physician request) with edit 22 (M/I DAW code) and the message “PA required – Brand

Medically Necessary”.

ACS will ensure that the only valid DAW codes will be 0, 1, and 5:




Date Rx Written and Date of Service

The system will enforce the following rules regarding the amount of time allowed between Date RX Written and Date of Service:

1.

If DEA = 2 (CII) – 5 (CV), then 30 days

2.

If DEA = 0, then 120 days

3.

Edit only applies to original prescriptions

Pricing

The following reimbursement structure is used by the MADAP program:



Payment for all except Syringes is Lesser of:




Allowable Cost:

63


Lesser of:

1. IDC,

2. EAC (lesser of): WAC+8%· Direct+8%· AWP - 12%,

3. FUL



Payment for syringes

Lesser of:

U&C or AWP + Dispensing Fee

Copays

ACS will ensure that MADAP claims do not have copays

Dispensing Fee

Brand Products = $3.69


Partial fills = ½ + ½ dispensing fee.

Drug Coverage

All medications on MADAP's formulary are covered and that list is below for reference.

Generic Brand name

Anti-

Ret Group Restrict

HRSA code

Drug

CD AppDT

1 Anti-retroviral NRTI N

2 Anti-retroviral NRTI N d04376 49 d05354 118

2/1/1999

8/1/2004 abacavir abacavir-lamivudine abacavir-zidovudinelamivudine

Ziagen

Epzicom acyclovir albuterol

Trizivir

Zovirax, Acyclovir

Proventil amitriptyline hydrochloride Elavil amlodipine (generic only)

Amoxil, Trimox, Wymox,

Biomox amoxicillin amoxicillin-clavulanate potassium amphotericin B amphotericin B cholesteryl sulfate amprenavir

Augmentin

Fungisone

Amphotec

Agenerase


0 Antiviral N

0 Bronchial Dilator N

0 Antidepressant N

0 Antihypertensive N

0 Antibiotics

0 Antibiotics

0 Antifungal

N

N

N

0 Antifungal N

1 Protease Inhibitor N d04727 79 d00001 03 d00749 107 d00146 81 d00689 134 d00088 101 d00089 95 d00077 04 d04100 106 d04428 58

1/1/1992

8/1/2004

2/28/2006

12/1/2003

12/1/2003

1/1/1992

5/3/2004

7/14/2000

64


atazanivir sulfate atenolol atorvastatin atovaquone azithromycin bupropion captopril cephalexin

Reyataz

(generic only)

Lipitor

Mepron, Malarone

Zithromax

Wellbutrin

(generic only)

Keflex, Keftab chlorothiazide cidofovir chlorothiazide

Vistide ciprofloxacin Cipro, Ciloxan citalopram hydrobromide Celexa clarithromycin clindamycin clonidine clotrimazole

Biaxin

Cleocin

(generic only)

Lotrimin, Mycelex clotrimazole-betamethasone Lotrisone Cream dapsone Dapsone darunavir daunorubicin citrate liposome

Prezista

DaunoXome

1 Protease Inhibitor N


0 Antilipemic Agent N

0 PCP Prophylaxis N

0 Mycobacterial

0 Antidepressant

0 Antihypertensive

0 Antibiotics

N

N

N

N

0 Antihypertensive

0 Antiviral

0 Antibiotics

0 Antidepressant

0 Mycobacterial

0 Toxoplasmosis

0 Antihypertensive

0 Antifungal

0 Antifungal

0 PCP Prophylaxis

N

N


N

N

N

N

N

N

N

N delavirdine didanosine diltiazem diphenoxylate-atropine

Rescriptor

Videx, ddl

(generic only)

Lomotil, Di-Atro

0 Neoplasm

1

Anti-retroviral

NNRTI

N

N



0 Antidiarrheal N

Antimanic/Anticonvu

0 lsant N

0 Antihypertensive N divalproex, valproic acid Depakote, Depakene doxazosin doxycycline

(generic only)

Doryx, Vibramycin,

Periostat efavirenz efavirenz/emtricitab/tenofov ir

Sustiva

Atripla emtricitabine Emtriva emtricitabine-tenofovir DF Truvada enfuvirtide Fuzeon epoetin alpha Procrit, Epogen

E-Base, Ery-Tab, E-

Mycin, Eryc erythromycin escitalopram oxalate ethambutol

Lexapro

Myambutol ethinyl estradiol-ethynodiol Zovia 1/50 ethinyl estradiolnorgestimate Sprintec 28

0 Antibiotics

Anti-retroviral

1 NNRTI

3

Anti-retroviral

NNRTI

N

N

N



1 Fusion Inhibitor Y

0 Cytokines-e Y

0 Antibiotics

0 Antidepressant

0 Mycobacterial

0 Contraceptive

0 Contraceptive

65


N

N

N

N

N d00037 96 d04355 43 d05825 150 d04884 108 d05352 117 d04853 89 d00223 47 d00046 102 d04812 109 d00068 07 d03388 141 d03781 139 d04882 90 d00004 129 d04105 69 d01120 21 d00091 29 d00181 73 d00006 126 d00096 103 d00190 145 d04028 35 d00011 65 d04332 82 d00097 22 d00043 39 d00044 137 d01236 05 d03561 83 d00098 25 d05825 148

12/1/2003

2/28/2006

5/5/2000

6/15/1993

7/14/2000

5/5/2000

2/28/2006

12/1/2003

2/28/2003

7/14/2000

7/14/2000

6/15/1993

7/14/2000

2/28/2006

1/1/1992

11/1/1994

7/12/2006 d04239 50 d04119 34 d00078 06 d00045 132 d03506 51 d03833 77 d00726 136

2/1/1999

7/14/2000

1/1/1992

2/28/2006

2/1/1999

5/5/2000

2/28/2006

12/1/2003

7/14/2000

7/12/2006

8/1/2004

8/1/2004

12/1/2003

2/1/1999

12/1/2003

8/1/2004

1/1/1992

2/28/2006

2/28/2006

famciclovir fenofibrate micronized filgrastim fluconazole fluoxetine fluphenazine fomivirsen fosamprenavir calcium foscarnet gabapentin ganciclovir gemfibrozil glimepiride glipizide haloperidol hydralazine hydrochlorothiazide hydroxyurea hydroxyzine

Famvir

Tricor

Neupogen

Diflucan

Prozac

Prolixin

Vitravene

Lexiva

Foscavir

Neurontin

Cytovene

(generic only)

Amaryl

Glucotrol

Haldol

(generic only) hydrochlorothiazide

Droxia

Atarax imiquimod indapamide indinavir insulin glargine insulin lispro insulin NPH interferon alpha-2A interferon alpha-2B isoniazid isoniazid-rifampin itraconazole ketoconazole lamivudine lamotrigine leucovorin levetiracetam levonorgestrel 0.75 mg lisinopril lithium carbonate loperamide lopinavir-ritonavir medroxyprogesterone megestrol acetate metformin HCL

Aldara Cream indapamide

Crixivan

Lantus

Humalog

Humulin N

Roferon-A

Intron-A

Nydrazid, INH

Rifamate

Sporanox

Nizoral

Epivir, 3TC

Lamictal

Leucovorin

Keppra

Plan B

(generic only)

Lithium Carbonate

Imodium

Kaletra

(generic only)

Megace

Glucophage

66


0 Antiviral N


0 Cytokines

0 Antifungal

Y

N

0 Antidepressant

0 Antipsychotic

N

N

0 Antiviral N


0 Antiviral

0 Anticonvulsant

N

N

0 Antiviral N


0 Unkn

0 Antidiabetic

0 Antipsychotic

0 Antihypertensive

N

N

N

N



0 Antianxiety

Immune Response

0 Modifier

N

N



0 Antidiabetic

0 Antidiabetic

0 Antidiabetic

0 Neoplasm

0 Neoplasm

0 Mycobacterial

N

N

N

N

N

N

0 Mycobacterial

0 Antifungal

0 Antifungal


0 Unkn

0 PCP Prophylaxis

N

N

N

N

N

0 Anticonvulsant

0 Contraceptive

0 Antihypertensive

0 Antimanic

0 Antidiarrheal N


0 Contraceptive

0 Wasting

0 Antidiabetic

N

N

N

N

N

N

N d03775 52 d04286 91 d00512 48 d00071 08 d00236 71 d00237 64 d04343 53 d04901 110 d00065 09 d03182 66 d00066 10 d00245 86 d03864 151 d00246 92 d00027 76 d00132 138 d00253 146 d01373 36 d00907 75 d04125 44 d00260 147 d03985 26 d04538 124 d04373 121 d04370 123 d01369 11 d01369 104 d00101 12 d03508 105 d00102 62 d00103 13 d03858 27 d03809 152 d00275 14 d04499 111 d03242 144 d00732 127 d00061 112 d01025 54 d04717 78 d00284 143 d01348 20 d03807 94

2/28/2006

6/15/1993

12/1/2003

7/14/2000

2/28/2006

7/14/2000

2/28/2006

2/28/2006

2/28/2006

5/1/1992

6/1/1992

5/1/1992

6/1/1992

7/14/2000

5/1/1992

7/14/2000

7/27/2006

5/1/1992

8/1/2004

2/28/2006

2/28/2006

8/1/2004

2/1/1999

2/1/1999

12/1/2003

2/1/1999

1/1/1992

5/5/2000

5/5/2000

2/1/1999

8/1/2004

5/1/1992

7/14/2000

5/1/1992

3/1/2003

7/27/2006

12/1/2003

5/5/2000

2/28/2006

2/28/2006

7/14/2000

5/5/2000

metoclopramide metoprolol metronidazole miconazole mirtazapine nandrolone nelfinavir

Reglan

(generic only)

Flagyl, Metryl, Protostat

Monistat

Remeron injection & patches

Viracept nevirapine nifedipine norethindrone nortriptyline nystatin octreotide olanzapine oxandrolone oxymetholone paromomycin paroxetine peginterferon alfa 2a peginterferon alfa 2b pentamidine perphenazine polymyxin B-trimethoprim sulfate pravastatin primaquine phosphate prochlorperazine propranolol pyrazinamide pyrimethamine quetiapine regular insulin ribavirin rifabutin rifampin risperidone ritonavir rosuvastatin saguinavir sertraline spironolactone stavudine sulfadiazine

Viramune

(generic only)

Errin

Pamelor, Aventyl

Mycostatin

Sandostatin

Zyprexa

Oxandrin

Anadrol-50

Humatin

Paxil

Pegasys

Peg-Intron

Pentam, NebuPent

Trilafon

Polytrim

Pravachol

Primaquine

Compazine

(generic only)

Rifater

Daraprim, Fansidar

Seroquel

Humulin R

Rebetol, Copegus

Mycobutin

Rifadin, Rimactane

Risperdal

Norvir

Crestor

Fortovase, SQV

Zoloft

(generic only)

Zerit, d4T

Sulfadiazine

67


0 Unkn

0 Antihypertensive

0 Antibiotics

0 Antifungal

0 Antidepressant

0 Wasting

N

N


Anti-retroviral

1 NNRTI N

N

N

N

N

0 Antihypertensive

0 Contraceptive

0 Antidepressant

0 Antifungal

0 Antidiarrheal

N

N

N

N

N

0 Antipsychotic

0 Wasting

0 Wasting

0 Antibiotics

0 Antidepressant

0 HepCVirus

0 HepCVirus

0 PCP Prophylaxis

0 Antipsychotic

N

N

Y

N

Y

N

Y

N

N

0 Antibiotics N


0 Antibiotics

0 Antiemetic

N

N

0 Antihypertensive

0 Mycobacterial

0 Toxoplasmosis

0 Antipsychotic

N

N

N

N

0 Antidiabetic

0 HepCVirus

0 Mycobacterial

0 Mycobacterial

0 Antipsychotic N




N

Y

N

N

0 Antidepressant

0 Antihypertensive

N

N


0 Toxoplasmosis N

7/27/2006

2/28/2006

12/1/2003

2/1/1999

8/1/2004

7/14/2000

7/14/2000

7/14/2000

2/28/2006

2/28/2006

7/14/2000

7/14/2000

2/1/1999

5/5/2000

7/14/2000

7/14/2000

7/14/2000

5/5/2000

12/1/2003

3/1/2003

1/1/1992

8/1/2004

8/1/2004

5/5/2000

12/1/2003

7/14/2000

2/28/2006

5/1/1992

5/1/1992

2/28/2006

2/28/2006

3/1/2003

6/15/1993

5/1/1992

5/5/2000

7/14/2000

4/27/2006

7/14/2000

5/5/2000

2/28/2006

11/1/1994

7/14/2000 d00298 153 d00134 130 d03208 97 d00155 55 d04025 113 d00568 42 d04118 32 d04029 30 d00051 135 d00555 142 d00144 40 d01233 59 d00370 56 d04050 63 d00566 46 d04295 61 d01104 67 d03157 70 d04821 93 d04746 87 d00030 02 d00855 114 d03529 115 d00348 68 d00351 98 d00355 60 d00032 131 d00117 15 d00364 16 d04220 120 d04374 122 d00085 88 d01097 23 d00047 17 d03180 74 d03984 28 d04851 149 d03860 37 d00880 72 d00373 128 d03773 24 d00118 38

tenofovir disoproxil fumarate testosterone transdermal thalidomide tipranavir

TMP-SMX trazadone HCL triamterene trimethoprim triphasic ethestradiolnorgestimate valacyclovir

Viread

Androderm, Androgel,

Testim

Thalomid

Aptivus

Bactrim, Septra, Septra

DS

Desyrel, Desyrel Dividose

(generic only)

Proloprim, Trimpex

Tri-Sprintec 28

Valtrex


0 Wasting

0 Wasting

N

N


0 PCP Prophylaxis

0 Antidepressant

0 Antihypertensive

0 Antibiotics

0 Contraceptive

0 Antiviral

N

N

N

N

N

N d04774 85 d00558 41 d04331 57 d05538 119 d00124 18 d00395 80 d00396 125 d00123 100 d03781 140 d03838 45 valganciclovir hydrochloride Valcyte venlafaxine HCL Effexor XR verapamil zalcitabine zidovudine

(generic only)

Hivid, ddC

Retrovir, AZT

0 Antiviral

0 Antidepressant

N

N



1 Anti-retroviral NRTI N d04755 84 d03181 116 d00048 133 d00127 19 d00034 01 zidovudine-lamivudine

Carbamazepine

Combivir

Tegretol, & XR


anticonvulsant N N d04219 33 d00058 154

NOTE:

Peginterferon alfa (including 2b and 2a) and ribavirin covered in combination, and only for treatment of HCV infection in HIV co-infected clients.

The following is a list of covered injectables:

Covered Injectable Products

1/1/2002

7/14/2000

2/1/1999

9/27/2005

5/1/1992

2/28/2006

12/1/2003

2/28/2006

7/14/2000

8/1/2004

2/28/2006

1/1/1993

1/1/1992

7/14/2000

10/26/06

HSN 006071

HSN 006072

HSN 007802

HSN 009792

HSN 004869

HSN 004182

HSN 010893

HSN 004128

HSN 010219

HSN 012800

HSN 006334

HSN 011506

Ciprofloxacin (Cipro i.v.)

Ciprofloxacin (Cipro i.v.)

Fluconazole (Diflucan)



Acyclovir (Zovirax)

Ampho B C-S (Amphotec)

Amphotericin-B (Fungisone)

Amphotericin-B Lipid Complex (Abelcet)

Amphotericin-B Liposome (Ambisome)

Azithromycin (Zithromax)

Cidofovir (Vistide)

68


HSN 004045

HSN 004704

HSN 010804

HSN 004013

HSN 025044

HSN 004553

HSN 006070

HSN 001624

HSN 001626

HSN 013221

HSN 001660

HSN 001661

HSN 001608

HSN 001063

HSN 004157

HSN 001413

HSN 002826

HSN 024035

HSN 021367

HSN 009599

HSN 001628

HSN 004040

HSN 001400

HSN 001401

Maintenance Drug List

Clindamycin (Cleocin)

Clindamycin (Cleocin)

Daunorubicin Citrate Liposomal (DaunoXorne)

Doxycyline (Vibramycin)

Enfuvirtide (Fuzeon)

Epoetin Alpha (Epogen, Procrit)

Filgrastim (Neupogen)

Fluphenazine (Prolixin, generics)

Fluphenazine (Prolixin, generics)

Foscarnet (Foscavir)

Haloperidol (Haldol)

Haloperidol (Haldol)

Hydroxizine (Atarax, Vistaril)

Leucovorin (Wellcovorin, generics)

Metronidazole (Flagyl)

Nandrolone (Nadrolone)

Octreotide (Sandostatin)

Peginterferon alfa 2a (Pegasys)

Peginterferon alfa 2b (Peg-Intron)

Pentamidine (Pentam, NebuPent

Prochloperazine (Compazine)

Rifampin (Rifadin, Rimactane)

Testosterone injection (Depo-Testosterone)

Testosterone injection (Delatestryl)

The MADAP maintenance drug list = antiretroviral therapies (NNRTIs, NRTIs, PIs,

Fusion Inhibitors).

Drugs Not Covered



Nutritional Supplements are not covered.



OTC products are not covered.

Prior Authorization

69


There are three places providers can obtain a Prior Authorization for the MADAP program: ACS, MADAP and SmartPA. Below will outline which drugs entity gives the

Prior Authorization for which category of drug.

PA Drug List

Drug Performed by

HSN 025044

HSN 004553

Enfuvirtie (Fuzeon)


PDCSx2

SmartPA


HSN 006070 SmartPA

HSN 001412 Oxandrolone (Oxandrin) SmartPA

PDCSx2

HSN 024035 Peginterferon alfa 2a (Pegasys)

PDCSx2

HSN 021367 Peginterferon alfa 2b (Peg-Intron)

HSN 004184 Ribavirin (Rebetol, Copegus)

PDCSx2

The ACS Technical Call Center will handle the following prior authorization requests for MADAP:

1. Early Refill

2. Quantity

3. Price - Per claim limit = $2500.00

The ACS PA Call Center will handle the following prior authorization requests for

MADAP:

1.

Epogen

2.

Neupogen

3.

Oxandrolone

The MADAP staff will handle all other prior authorization requests.

SmartPA

70


SmartPA is a rules engine driven program that will search existing claim and medical history to evaluate whether or not the recipient has met the set criteria to receive the drug being billed. If the recipient meets criteria then the system generates a Prior

Authorization and the claim is paid. If the recipient does not meet criteria, the claim is denied with a SmartPA specific edit advising which criteria was not met.

The following categories are submitted to SmartPA for evaluation:









Oxandrolone (Oxandrin)

Copay Only Claim Billing Guidelines

MADAP will allow providers to bill for a copay only claim. In order for the claim to be processed correctly, the following guidelines must be followed.

The system will require claims for COB copay only billing to adhere to the following

NCPDP parameters:

1.

NO COB SEGMENT SUBMITTED

2.

OCC = 8

3.

Other Amount Claimed Qualifier = 99

4.

Other Amount Claimed = Amount of copay

5.

Gross Amount Due = Equal Other Amount Claimed/Amount of copay

6.

Other Amount Claimed Submitted must be the entire patient copay as charged by the pharmacy

71


Maryland Kidney Disease Program (KDP)

This section will outline program specific information that is not covered in the beginning of this manual.

Generic Mandatory and Dispense as Written Code Usage

KDP has a generic mandatory program in place that must be followed. When providers submit a claim for a drug that has a generic equivalent and there is no active PA on file or appropriate DAW code, the claim will deny with an NCPDP Reject code ‘22’ – M/I DAW

Code.

KDP accepts the following DAW codes:

ACS will ensure that the only valid DAW codes will be 0, 1, 5 and 6:




6 – Client Override

KDP allows the use of DAW 6 for medications determined by KDP as follows (pay at

EAC):

Duragesic NDCs: 50458003305, 50458003405, 50458003505, 50458003605,

50458003705

Rebetol NDCs: 00085119403, 00085132704, 00085135105, 00085138507

Flonase NDCs: 00173045301

Zocor NDCs: 00006073531, 00006073528, 00006073554, 00006073582, 00006073587,

00006074087, 00006074028, 00006074031, 00006074054, 00006074082, 00006074954,

00006074982, 00006074928, 00006074931, 00006072631, 00006072628, 00006072654,

00006072682, 00006054331, 00006054328, 00006054382, 00006054354.

LTC

The KDP system has no LTC recipients and will reject claims submitted with LTC identifiers (NCPDP field 307-C7, Patient Location = 3 – Nursing Home or 4-Long

Term/Extended Care) with NCPDP edit 70 and message text: “LTC Claims Not Allowed for Reimbursement”.

72


Minimum / Maximum Quantities

The KDP program enforces the following Minimum / Maximum quantity limits:

A max quantity limit of 350 for the following Immunosuppressive Oral tablets/capsules will be enforced.

1.

Azathioprine

2.

Cyclosporine

3.

Mycophenolate Mofetil (Cellcept)

4.

Sirolimus (Rapamume)

5.

Tacrolimus (Prograf)

6.

HSN = 004523, 004524, 010086, 010012, 020519, 008974; and Route

= Oral

There is a max quantity limit of 350 for Immunosuppressants, Oral tablets/capsules.

The max quantity limit for Oxycontin (GSN = 024505, 024506, 025702, 024504,

045129) is 120. Note: This is a per fill quantity limit, not an accumulation limit.

Minimum Quantity

There is a minimum quantity limit of 100 tablets for Ferrous sulfate 325mg tablets (GSN

= 001645, 001646, 017378).

A minimum quantity limit of 480 ml for Ferrous sulfate elixir (220mg/5ml), GSN =

001639) will be applied.

KDP will enforce a minimum quantity limit of 60 tablets for non-legend chewable tablets of any ferrous salt when combined with vitamin C, multivitamins, multivitamins and minerals, or other minerals in the formulation (HIC3 = C3B; and Dosage form = TC).

Date of Rx Written and Date of Service

73


The system will enforce the following rules regarding the amount of time allowed between Date RX Written and Date of Service:

1.

No greater than 10 days.

2.

Claims greater than this 10 day limit will deny for NCPDP Error

Code M4 (Prescription Number/Time Limit Exceeded).

3.

Edit only applies to original prescriptions.

Unit Dose

The system will deny claims for unit dose medications with the exception of drugs listed below with error 70 (drug not covered) and message text: “Unit Dose Package Size”.

Unit Dose Drugs Exceptions for Retail Claims (all other U/D will deny with NCPDP 70 – NDC not covered)/ “Unit Dose Package Size”

HSN = 000739; and UD Ferrous Sulfate (single ingredient products only)

Micardis 20mg, 40mg & 80mg GSN = 040910, 040911,

047126; and UD

GSN = 011964, 011963,

023881, 023882; and UD

GSN = 031055, 031056; and

UD

GSN = 049296, 040887; and

UD

GSN = 009326, 009327; and

UD

GSN = 018370; and UD

Cyclosporine 25mg & 100mg caps

Pepcid RPD

Prevacid Liquid

Vancocin HCL

Bactroban Nasal

Includes Gengraf

Pricing

ACS will ensure the claims reimburse at the following pricing:

1.

Legend Drugs, Schedule V Cough Preps, Enteric Coated

Aspirin, Oral Ferrous Sulfate Prods



Allowable Cost is lLesser of:

1. IDC,

74


2. EAC (lesser of): WAC+8%· Direct+8%· Distributors +

8%· AWP - 12%,

3. FUL

2.

Chewable Ferrous Sulfate with Multivitamins


U/C -or- Allowable Cost + 50% -or- Allowable Cost +

Dispensing Fee

Allowable Cost is lesser of:

1. IDC

2. EAC (lesser of): WAC+8% -or- Direct+8% -or-

Distributors + 8% -or- AWP - 12%

3. FUL

3.

DAW 1 and 6 Claims



Allowable Cost:

EAC (lesser of): · WAC+8% -or- Direct+8% -or-

Distributors + 8% -or- AWP – 12%

4.

Other OTC Drugs (Insulin and Nutritional Supplements)


U/C -or- Allowable Cost + 50% -or- Allowable Cost +

Dispensing Fee

Allowable Cost: AWP

5.

Medical Supplies and Durable Medical Equip (Needles and

Syringes)



Allowable Cost: AWP

ACS will ensure that KDP claims do not have copays.

ACS will ensure that claims will reimburse with the following dispensing fee:

75


Dispensing Fee

Brand Products = $2.69


Partials fills – ½ + ½ dispensing fee.

Copays

KDP recipients do not have copays.

Prior Authorizations

The ACS Technical Call Center will handle the following prior authorization requests for

KDP:

1. Early Refill

2. Quantity

3. Price - Per claim limit = $2500.00

The KDP staff will handle the following prior authorization requests:

1.

Early Refills for requests outside established criteria

2.

Nutritional supplements for specific NDCs

3.

DME/DMS for HCFA 1500 billing - Exception: needles, syringes, blood glucose test strips

Providers can reach the KDP prior authorization staff at 410-767-5000 or 5002, M-F,

8:00 am – 4:30 pm.

Appendix E

EDITS

76


6/20/03 39

ON-LINE CLAIMS PROCESSING MESSAGES:

Following an on-line claim submission by a pharmacy, the system will return a message to indicate the outcome of processing. If the claim passes all edits, a “Paid” message will be returned with Maryland Medicaid’s allowed amount for the paid claim. A claim that fails an edit and is rejected (denied) will also return a message. Following is a list of the program’s error codes with their corresponding NCPDP reject codes.

As shown below, the NCPDP error code is returned with the NCPDP message.

Additionally, supplemental messages are sometimes returned in the additional message field of the claim that may be helpful in resolving the specific error. Where applicable, the NCPDP field that should be checked is referenced. Check the Solutions box if you are experiencing difficulties. For further assistance contact

AFFILIATED COMPUTER SERVICES, INC.at:

MA, MPAP & MPDP 1- 800-932-3918

KDP 1- 800-884-7387

(Nationwide Toll Free Number)

POINT OF SALE REJECT CODES AND MESSAGES

~ All edits may not apply to this program ~

RejectCode

Explanation Check NCPDP Field #

Possible Solutions

ØØ ("M/I" = Missing/Invalid)

Ø1 M/I Bin 1Ø1 ØØ9753 (MD MEDICAID)

Ø1Ø454 (MD KDP)

Ø2 M/I Version Number 1Ø2 Versions allowed = 5.1

Ø3 M/I Transaction Code 1Ø3 Transactions allowed = B1, B2, B3

Ø4 M/I Processor Control Number 1Ø4 PØ1ØØØ9753 (MD Medicaid)

PØ12Ø1Ø454 (MD KDP)

Ø5 M/I Pharmacy Number 2Ø1 NABP/ NCPDP number only. Check with software vendor to ensure appropriate number has been set up in your system.

Ø6 M/I Group Number 3Ø1 MDMEDICAID - Maryland Medicaid.

MDKDP - Maryland KDP

Ø7 M/I Cardholder ID Number 3Ø2 KDP Recipient Number plus 5 leading zeros only.

MD Medicaid Recipient ID number only, do not use any other patient ID. Do not enter any dashes. Providers should always examine a recipient’s Medicaid ID card before services are rendered. It is the provider’s responsibility to establish the identity of the recipient and to verify the effective date of coverage for the card

77


presented.

Ø8 M/I Person Code 3Ø3

Ø9 M/I Birth Date 3Ø4 Format = CCYYMMDD.

1C M/I Smoker/Non-Smoker Code 334

1E M/I Prescriber Location Code 467

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Reject

Code

Explanation Check NCPDP

Field #

Possible Solutions

1Ø M/I Patient Gender Code 3Ø5 Values = 0/ not specified; 1/ male and 2/ female.

11 M/I Patient Relationship Code 3Ø6 Allowed value = 1 (cardholder)

12 M/I Patient Location 3Ø7 Allowed value = 03/ nursing home, 11/ hospice

13 M/I Other Coverage Code 3Ø8 See Coordination of Benefits section.

14 M/I Eligibility Clarification Code 3Ø9

15 M/I Date of Service 4Ø1 Format = CCYYMMDD.

16 M/I Prescription/Service Reference Number 4Ø2 Format = NNNNNNN.

17 M/I Fill Number 4Ø3 Allowed value varies based on drug DEA code. See Dispensing Limits section. If a value is entered in the field “NUMBER OF

REFILLS AUTHORIZED” (#415), the value in the NEW/ REFILL CODE field must not exceed the number of refills authorized.

19 M/I Days Supply 4Ø5 Format = NNN. “PRN” not allowed

2C M/I Pregnancy Indicator 335

2E M/I Primary Care Provider ID Qualifier 468

2Ø M/I Compound Code 4Ø6 Values = 0/ not specified; 1/ not a compound and 2/ compound. See Compound Claim.

21 M/I Product/Service ID 4Ø7 Use 11-digit NDC only. Do not enter any dashes.

22 M/I Dispense As Written (DAW)/Product Selection Code 4Ø8

23 M/I Ingredient Cost Submitted 4Ø9

25 M/I Prescriber ID Valid DEA number.

26 M/I Unit Of Measure 6ØØ

28 M/I Date Prescription Written 414 Format = CCYYMMDD. Must be =/ <

DOS.

29 M/I Number Refills Authorized 415

3A M/I Request Type 498-PA

3B M/I Request Period Date-Begin 498-PB

78


3C M/I Request Period Date-End 498-PC

3D M/I Basis Of Request 498-PD

3E M/I Authorized Representative First Name 498-PE

3F M/I Authorized Representative Last Name 498-PF

3G M/I Authorized Representative Street Address 498-PG

3H M/I Authorized Representative City Address 498-PH

3J M/I Authorized Representative State/Province Address 498-PJ

3K M/I Authorized Representative Zip/Postal Zone 498-PK

3M M/I Prescriber Phone Number 498-PM

3N M/I Prior Authorized Number Assigned 498-PY

3P M/I Authorization Number 5Ø3

3R Prior Authorization Not Required 4Ø7

3S M/I Prior Authorization Supporting Documentation 498-PP

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Reject

Code


Field #

Possible Solutions

3T Active Prior Authorization Exists Resubmit At Expiration

Of Prior Authorization

3W Prior Authorization In Process

3X Authorization Number Not Found 5Ø3

3Y Prior Authorization Denied

32 M/I Level Of Service 418

33 M/I Prescription Origin Code 419

34 M/I Submission Clarification Code 42Ø

35 M/I Primary Care Provider ID 421

38 M/I Basis Of Cost 423

39 M/I Diagnosis Code 424

4C M/I Coordination Of Benefits/Other Payments Count 337

4E M/I Primary Care Provider Last Name 57Ø

4Ø Pharmacy Not Contracted With Plan On Date Of Service None NABP/NCPDP number only; check DOS.

Call the Provider Enrollment Department if necessary.

41 Submit Bill To Other Processor Or Primary Payer None Indicates patient shows other coverage on eligibility file. See Coordination of Benefits section.

5C M/I Other Payer Coverage Type 338 Use valid NCPDP values.

5E M/I Other Payer Reject Count 471

79


5Ø Non-Matched Pharmacy Number 2Ø1 NABP/NAPDP number only.

51 Non-Matched Group ID 3Ø1 MDMEDICAID - Maryland Medicaid only.

MDKDP - Maryland KDP only.

52 Non-Matched Cardholder ID 3Ø2 KDP Recipient Number only, do not use any other patient ID. Do not enter any dashes.

Maryland Medicaid ID number only, do not use any other patient ID. Do not enter any dashes.

53 Non-Matched Person Code 3Ø3

54 Non-Matched Product/Service ID Number 4Ø7 11 digit NDC

55 Non-Matched Product Package Size 4Ø7

56 Non-Matched Prescriber ID 411 Validate DEA number.

58 Non-Matched Primary Prescriber 421

6C M/I Other Payer ID Qualifier 422 Use “99” (Other) only.

6E M/I Other Payer Reject Code 472

6Ø Product/Service Not Covered For Patient Age 3Ø2, 3Ø4,

4Ø1, 4Ø7

61 Product/Service Not Covered For Patient Gender 3Ø2, 3Ø5, 4Ø7

62 Patient/Card Holder ID Name Mismatch 31Ø, 311, 312,

313, 32Ø

Ensure first/ last name entered as on the recipient Medicaid ID card.

63 Institutionalized Patient Product/Service ID Not Covered

64 Claim Submitted Does Not Match Prior Authorization 2Ø1, 4Ø1,

4Ø4, 4Ø7, 416

65 Patient Is Not Covered 3Ø3, 3Ø6

EDITS

6/20/03 42

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Reject

Code


Field #

Possible Solutions

66 Patient Age Exceeds Maximum Age 3Ø3, 3Ø4, 3Ø6

67 Filled Before Coverage Effective 4Ø1 KDP Recipient number and 5 leading zero’s only.

Maryland Medicaid ID number only.

Do not use any other patient ID. Do not enter any dashes. Check DOS. Check Group

Number.

68 Filled After Coverage Expired 4Ø1 KDP Recipient number and 5 leading zero’s only.

Maryland Medicaid ID number only.

80


Do not use any other patient ID. Do not enter any dashes. Check DOS. Check Group

Number.

69 Filled After Coverage Terminated 4Ø1

7C M/I Other Payer ID 34Ø

7E M/I DUR/PPS Code Counter 473

7Ø Product/Service Not Covered 4Ø7 Drug not covered.

71 Prescriber Is Not Covered 411

72 Primary Prescriber Is Not Covered 421

73 Refills Are Not Covered 4Ø2, 4Ø3 Accepted value varies based on drug DEA code. See Dispensing Limits section.

74 Other Carrier Payment Meets Or Exceeds Payable 4Ø9, 41Ø, 442

75 Prior Authorization Required 462 Drug requires PA.

76 Plan Limitations Exceeded 4Ø5, 442 Check days supply and metric decimal quantity.

77 Discontinued Product/Service ID Number 4Ø7 Use valid, current 11-digit NDC.

78 Cost Exceeds Maximum 4Ø7, 4Ø9,

41Ø, 442

79 Refill Too Soon 4Ø1, 4Ø3, 4Ø5 Non-controlled substances:



80% use requirement if < 90 day supply



90% use requirement if >/= 90 day supply

Controlled substances:

85% use requirement (15% tolerance) all claims

8C M/I Facility ID 336

8E M/I DUR/PPS Level Of Effort 474

8Ø Drug-Diagnosis Mismatch 4Ø7, 424

81 Claim Too Old 4Ø1 Check DOS.

82 Claim Is Post-Dated 4Ø1 Check DOS.

83 Duplicate Paid/Captured Claim 2Ø1, 4Ø1,

4Ø2, 4Ø3, 4Ø7

84 Claim Has Not Been Paid/Captured 2Ø1, 4Ø1, 4Ø2

85 Claim Not Processed None

86 Submit Manual Reversal None

87 Reversal Not Processed None

88 DUR Reject Error Enter the appropriate Reason for Service,

Result of Service and Professional Service if applicable.

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6/20/03 43

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ERSION 5.Ø R EJECT

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TANDARD

Reject

Code


81


Field #

Possible Solutions

89 Rejected Claim Fees Paid

9Ø Host Hung Up Host Disconnected Before Session

Completed.

91 Host Response Error Response Not In Appropriate Format To

Be Displayed.

92 System Unavailable/Host Unavailable Processing Host Did Not Accept

Transaction/Did Not Respond Within

Time Out Period.

95 Time Out

96 Scheduled Downtime

97 Payer Unavailable

98 Connection To Payer Is Down

99 Host Processing Error Do Not Retransmit Claim(s).

AA Patient Spend-down Not Met

AB Date Written Is After Date Filled

AC Product Not Covered Non-Participating Manufacturer

AD Billing Provider Not Eligible To Bill This Claim Type

AE QMB (Qualified Medicare Beneficiary)-Bill Medicare

AF Patient Enrolled Under Managed Care

AG Days Supply Limitation For Product/Service

AH Unit Dose Packaging Only Payable For Nursing Home

Recipients

AJ Generic Drug Required

AK M/I Software Vendor/Certification ID 11Ø

AM M/I Segment Identification 111

A9 M/I Transaction Count 1Ø9

BE M/I Professional Service Fee Submitted 477

B2 M/I Service Provider ID Qualifier 2Ø2

CA M/I Patient First Name 31Ø Check spelling of patient first name on ID card.

CB M/I Patient Last Name 311 Check spelling of patient last name on ID card.

CC M/I Cardholder First Name 312 Check spelling of patient first name on ID card.

CD M/I Cardholder Last Name 313

CE M/I Home Plan 314

CF M/I Employer Name 315

CG M/I Employer Street Address 316

CH M/I Employer City Address 317

CI M/I Employer State/Province Address 318

CJ M/I Employer Zip Postal Zone 319

EDITS

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6/20/03 44

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Reject

Code


Field #

Possible Solutions

CK M/I Employer Phone Number 32Ø

CL M/I Employer Contact Name 321

CM M/I Patient Street Address 322

CN M/I Patient City Address 323

CO M/I Patient State/Province Address 324

CP M/I Patient Zip/Postal Zone 325

CQ M/I Patient Phone Number 326

CR M/I Carrier ID 327

CW M/I Alternate ID 33Ø

CX M/I Patient ID Qualifier 331

CY M/I Patient ID 332

CZ M/I Employer ID 333

DC M/I Dispensing Fee Submitted 412

DN M/I Basis Of Cost Determination 423

DQ M/I Usual And Customary Charge 426

DR M/I Prescriber Last Name 427

DT M/I Unit Dose Indicator 429

DU M/I Gross Amount Due 43Ø

DV M/I Other Payer Amount Paid 431 Enter any amount(s) received from other payer(s).

DX M/I Patient Paid Amount Submitted 433

DY M/I Date Of Injury 434

DZ M/I Claim/Reference ID 435

EA M/I Originally Prescribed Product/Service Code 445

EB M/I Originally Prescribed Quantity 446

EC M/I Compound Ingredient Component Count 447

ED M/I Compound Ingredient Quantity 448

EE M/I Compound Ingredient Drug Cost 449

EF M/I Compound Dosage Form Description Code 45Ø

EG M/I Compound Dispensing Unit Form Indicator 451

EH M/I Compound Route Of Administration 452

EJ M/I Originally Prescribed Product/Service ID Qualifier 453

EK M/I Scheduled Prescription ID Number 454

EM M/I Prescription/Service Reference Number Qualifier 445

EN M/I Associated Prescription/Service Reference Number 456

EP M/I Associated Prescription/Service Date 457

ER M/I Procedure Modifier Code 459

83


ET M/I Quantity Prescribed 46Ø

EU M/I Prior Authorization Type Code 461 Use NCPDP valid values.

EDITS

6/20/03 45

V

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S

TANDARD

Reject

Code


Field #

Possible Solutions

EV M/I Prior Authorization Number Submitted 462

EW M/I Intermediary Authorization Type ID 463

EX M/I Intermediary Authorization ID 464

EY M/I Provider ID Qualifier 465

EZ M/I Prescriber ID Qualifier 466 Use 12 = DEA

E1 M/I Product/Service ID Qualifier 436 Use 03 = NDC

E3 M/I Incentive Amount Submitted 438

E4 M/I Reason For Service Code 439 See Prospective Drug Utilization Review section.

E5 M/I Professional Service Code 44Ø See Prospective Drug Utilization Review section.

E6 M/I Result Of Service Code 441 See Prospective Drug Utilization Review section.

E7 M/I Quantity Dispensed 442 Format = 99999.999.

E8 M/I Other Payer Date 443

E9 M/I Provider ID 444

FO M/I Plan ID 524

GE M/I Percentage Sales Tax Amount Submitted 482

HA M/I Flat Sales Tax Amount Submitted 481

HB M/I Other Payer Amount Paid Count 341

HC M/I Other Payer Amount Paid Qualifier 342

HD M/I Dispensing Status 343

HE M/I Percentage Sales Tax Rate Submitted 483

HF M/I Quantity Intended To Be Dispensed 344

HG M/I Days Supply Intended To Be Dispensed 345

H1 M/I Measurement Time 495

H2 M/I Measurement Dimension 496

H3 M/I Measurement Unit 497

H4 M/I Measurement Value 499

H5 M/I Primary Care Provider Location Code 469

H6 M/I DUR Co-Agent ID 476

H7 M/I Other Amount Claimed Submitted Count 478

H8 M/I Other Amount Claimed Submitted Qualifier 479

H9 M/I Other Amount Claimed Submitted 48Ø

84


JE M/I Percentage Sales Tax Basis Submitted 484

J9 M/I DUR Co-Agent ID Qualifier 475

KE M/I Coupon Type 485

M1 Patient Not Covered In This Aid Category

M2 Recipient Locked In

M3 Host PA/MC Error

EDITS

6/20/03 46

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TANDARD

Reject

Code


Field #

Possible Solutions

M4 Prescription/Service Reference Number/Time Limit

Exceeded

M5 Requires Manual Claim

M6 Host Eligibility Error

M7 Host Drug File Error

M8 Host Provider File Error

ME M/I Coupon Number 486

MZ Error Overflow

NE M/I Coupon Value Amount 487

NN Transaction Rejected At Switch Or Intermediary

PA PA Exhausted/Not Renewable

PB Invalid Transaction Count For This Transaction Code 1Ø3, 1Ø9

PC M/I Claim Segment 111

PD M/I Clinical Segment 111

PE M/I COB/Other Payments Segment 111

PF M/I Compound Segment 111

PG M/I Coupon Segment 111

PH M/I DUR/PPS Segment 111

PJ M/I Insurance Segment 111

PK M/I Patient Segment 111

PM M/I Pharmacy Provider Segment 111

PN M/I Prescriber Segment 111

PP M/I Pricing Segment 111

PR M/I Prior Authorization Segment 111

PS M/I Transaction Header Segment 111

PT M/I Workers’ Compensation Segment 111

PV Non-Matched Associated Prescription/Service Date 457

PW Non-Matched Employer ID 333

PX Non-Matched Other Payer ID 34Ø

PY Non-Matched Unit Form/Route of Administration 451, 452, 6ØØ

85


PZ Non-Matched Unit Of Measure To Product/Service ID 4Ø7, 6ØØ

P1 Associated Prescription/Service Reference Number Not

Found

456

P2 Clinical Information Counter Out Of Sequence 493

P3 Compound Ingredient Component Count Does Not Match

Number Of Repetitions

447

P4 Coordination Of Benefits/Other Payments Count Does

Not Match Number Of Repetitions

337

P5 Coupon Expired 486

P6 Date Of Service Prior To Date Of Birth 3Ø4, 4Ø1

EDITS

6/20/03 47

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Reject

Code


Field #

Possible Solutions

P7 Diagnosis Code Count Does Not Match Number Of

Repetitions

491

P8 DUR/PPS Code Counter Out Of Sequence 473

P9 Field Is Non-Repeatable

RA PA Reversal Out Of Order

RB Multiple Partials Not Allowed

RC Different Drug Entity Between Partial & Completion

RD Mismatched Cardholder/Group ID-Partial To

Completion

3Ø1, 3Ø2

RE M/I Compound Product ID Qualifier 488

RF Improper Order Of ‘Dispensing Status’ Code On Partial

Fill Transaction

RG M/I Associated Prescription/service Reference Number

On Completion Transaction

456

RH M/I Associated Prescription/Service Date On Completion

Transaction

457

RJ Associated Partial Fill Transaction Not On File

RK Partial Fill Transaction Not Supported

RM Completion Transaction Not Permitted With Same ‘Date

86


Of Service’ As Partial Transaction

4Ø1

RN Plan Limits Exceeded On Intended Partial Fill Values 344, 345

RP Out Of Sequence ‘P’ Reversal On Partial Fill Transaction

RS M/I Associated Prescription/Service Date On Partial

Transaction

457

RT M/I Associated Prescription/Service Reference Number

On Partial Transaction

456

RU Mandatory Data Elements Must Occur Before Optional

Data Elements In A Segment

R1 Other Amount Claimed Submitted Count Does Not Match

Number Of Repetitions

478, 48Ø

R2 Other Payer Reject Count Does Not Match Number Of

Repetitions

471, 472

R3 Procedure Modifier Code Count Does Not Match Number

Of Repetitions

458, 459

R4 Procedure Modifier Code Invalid For Product/Service ID 4Ø7, 436, 459

R5 Product/Service ID Must Be Zero When Product/Service

ID Qualifier Equals Ø6

4Ø7, 436

R6 Product/Service Not Appropriate For This Location 3Ø7, 4Ø7, 436

R7 Repeating Segment Not Allowed In Same Transaction

R8 Syntax Error

R9 Value In Gross Amount Due Does Not Follow Pricing

Formulae

43Ø

SE M/I Procedure Modifier Code Count 458

TE M/I Compound Product ID 489

EDITS

6/20/03 48

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T

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S

TANDARD

Reject

Code


Field #

Possible Solutions

UE M/I Compound Ingredient Basis Of Cost Determination 49Ø

VE M/I Diagnosis Code Count 491

WE M/I Diagnosis Code Qualifier 492

87


XE M/I Clinical Information Counter 493

ZE M/I Measurement Date 494

EDITS

6/20/03 49

Host System Problems:

Occasionally providers may receive a message that indicates their network is having technical problems communicating with FIRST HEALTH SERVICES.

NCPDP Message

90 Host Hung Up

Host disconnected before session completed.

NCPDP Message

92 System Unavailable/Host Unavailable

Processing host did not accept transaction or did not respond within time out period.

NCPDP Message

93 Planned Unavailable

Transmission occurred during scheduled downtime. AFFILIATED COMPUTER

SERVICES, INC.will provide system availability from:



4:00 AM – 3:00 AM, EST Monday through Saturday;



4:00 AM – 10:00 PM, EST Sunday.

NCPDP Message

99 Host Processing Error

Do not retransmit claims.

EDITS

6/20/03 50

DUR Fields:

When denials for ProDUR edits are received, providers may override these denials using the appropriate

DUR Reason of Service (Conflict), Professional Results (Intervention), and Result of

Service (Outcome

Codes), with the exception of Early Refill (ER). Following are the ProDUR edits that will deny for

Maryland Medicaid:



Early Refill (ER) – providers must contact the First Health Technical Call Center to request overrides (provider overrides not allowed).



Therapeutic Duplication (TD) - selected therapeutic classes deny, others return warning message only.



Acute to Maintenance Anti-Ulcer Protocol (PP)

NCPDP Message

88 DUR Reject Error

88


 MA, MPAP & MPDP Therapeutic Duplication Denial NCPDP 88, ‘DUR Reject Error

TD’.

Alpha-Adrenergic Blocking Agents

Anticholinergics/Antispasmodics

Antihistamines

Barbiturates

Bile Salt Sequestrants

Bile Salts

Calcium Channel Blocking Agents

Cerivastin, Lovastatin, Simvastatin, Pravastatin, Fluvastatin, Atrovastatin

Diabetic Therapy

Digitalis Glycosides


Hypotensives, ACE Inhibitors

Hypotensives, Sympatholytic

Hypotensives, Vasolidators

Loop Diuretics

NSAIDS

Potassium Sparing Diuretics

Psychostimulants-Antidepressants

Quinolones

Thiazide and Related Diuretics

EDITS

6/20/03 51



MA, MPAP & MPDP and KDP ProDUR Acute to Maintenance Anti-Ulcer (Brand only and acute dose exceeds 68 days) NCPDP 88, ‘DUR Reject Error PP’. The diagnosis must be written on the prescription and the diagnosis must be included on the list of acceptable diagnoses.

Acceptable Diagnoses for Continued Use of H2 Blockers and PPIs at acute doses beyond

68 days:

 Barrett’s Disease, Barrett Esophagitis, Barrett’s Esophagatus or Esophagus, Barrett’s

Epithelium,

Esophageal tumors, etc.)



GERD (Gastroesophageal Reflux Disease, Reflux, Reflux Disease, or Reflux

Esophagitis, or

Peptic Esophagitis), Esophagitis, Gastroesophagitis, Erosive or Ulcerative Esophagitis)



Hiatal Hernias, Symptomatic Hiatal Hernias, etc.



Pathological Hypersecretory Conditions (including ZE Syndrome)



Unhealed Ulcers



Wermer (Endocrine Adenoma-Peptic Ulcer Complex; Multiple Endocrine Neoplasias;

Pluriglandular Adenomatosis etc.)



ZE (Zollinger-Ellison Syndrome, Strom-Zollinger-Ellison, Gastrinoma, Multiple Partial

89


Endocrine Adenomatosis, Multiple Partial Adenomatosis; Pancreatic Ulcerogenic or

Polyglandular Adenomatosis, Systemic Mastocytosis)

Drug Acute Dose

Cimetidine (Tagamet



) >/= 800mg/day

Esomeprazole (Nexium



) >/= 40mg/day

Famotidine (Pepcid



) >/= 40mg/day

Lansoprazole (Prevacid



) >/= 30mg/day

Nizatidine (Axid



) >/= 300mg/day

Omeprazole (Prilosec



) >/= 40mg/day

Pantoprazole (Protonix



) >/= 80mg/day

Rabeprazole (Aciphex



) >/= 40mg/day

Ranitidine (Zantac



) >/= 300mg/day

EDITS

6/20/03 52



KDP ProDUR Therapeutic Duplication Denial NCPDP 88, ‘DUR Reject Error TD’.

Alpha-Adrenergic Blocking Agents

Antihistamines

Barbiturates

Calcium Channel Blocking Agents

Diabetic Therapy

Digitalis Glycosides


Hypotensives, ACE Inhibitors

Hypotensives, Sympatholytic

Hypotensives, Vasolidators

Loop Diuretics

NSAIDS

Potassium Sparing Diuretics

Psychostimulants-Antidepressants

Quinolones

Thiazide and Related Diuretics

Note: Provider overrides are on a per claim (date of service only) basis. For quality of care purposes, pharmacists are required to retain documentation relative to these overrides.

EDITS

6/20/03 53

DUR Reason for Service/ Conflict Code:



The DUR Reason for Service is used to define the type of utilization conflict that was detected

(NCPDP field 439).



Valid DUR Reason for Service for the MA, MPAP & MPDP and KDP are:



ER = EARLY REFILL



TD = THERAPEUTIC DUPLICATION

90




PP = PLAN PROTOCOL (ACUTE TO MAINTENANCE

ANTI-ULCER)

NCPDP Message

E4 M/I DUR conflict/reason for service code

DUR Professional Service/ Intervention Code:



The DUR Professional Service is used to define the type of interaction or intervention that was performed by the pharmacist (NCPDP field 440).



Override Codes: Designated Professional Service must accompany the designated

Result of Service to allow the override.

NCPDP Message

E5 M/I DUR intervention/professional service code

DUR Result of Service/ Outcome Code:



The DUR Result of Service is used to define the action taken by the pharmacist in response to a

ProDUR Reason for Service or the Result of Service (NCPDP field 441).



Override Codes: Note that designated Professional Service must accompany the designated Result of

Service to allow the override.

NCPDP Message

E6 M/I DUR outcome/ result of service code

Override Codes for both Maryland Medicaid and KDP: the following codes will be used to allow for provider level overrides for Therapeutic Duplication (TD), and Plan Protocol (PP) denials.

Professional Service/ Description (NCPCP field #440-E5)

Result of Service/ Description (NCPDP field #441-E6)

00/ no intervention

M0/ prescriber consulted

PE/ patient education

P0/ patient consulted

R0/ pharmacist consulted other source

1A/ filled as is, false positive

1B/ filled prescription as is

1C/ filled with different dose

1D/ filled with different directions

1F/ filled with different quantity

1G/ filled with prescriber approval

APPENDIX A

PAYER

SPECIFICATIONS

4/16/03 A

APPENDIX B

91


OTHER CARRIER

CODE LIST

4/16/03 B.1

OTHER_PAYER_ID OTHER_PAYER_NAME

I0288 ADVANCE PARADIGM

I1413 ADVANCED PCS

I1606 AETNA PHARMACY

I0340 AETNA PHARMACY MANAGEMENT

I1414 AETNA SERVICES INC

I1647 AETNA US HEALTHCARE

AT531 ALLIANCE PPO MAPST

I0255 AMERICAN COMMUNITY MUTUAL INS

I0411 ASSOCIATE PRESCRIPTION SERVICE

BB24D BC BS OF MD FED EMPLOYEES

AO655 BC/BS

I1758 BLUE CROSS BLUE SHIELD

I1174 CAREFIRST

BB24A CAREFIRST B/C B/S OF MD

AU146 CAREMARK

AY314 CAREMARK

I0530 CAREMARK

I0668 CAREMARK

I0691 CAREMARK

I1535 CAREMARK

AP622 CIGNA HEALTH CARE

I0534 CIGNA HEALTH CARE

AR983 CIGNA HEALTH PLAN

I1782 CIGNA PHARMACY

I1338 CIGNA RX

I1317 CLAIMS PRO

I0680 DIVERSIFIED PHARMACEUTICAL

I1329 ECKERD PHARMACY SERV

I1206 EXPRESS SCRIPT

I1061 EXPRESS SCRIPT VALUE RX

I0559 EXPRESS SCRIPTS





I1379 EXPRESS SCRIPTS/GOODYEAR

I0592 MEDCO

I0504 MEDCO BEHAVIORAL CARE

QD174 MEDCO MNG CARE-AIM COMP ASSOC

I0766 MERCK MEDCO

92


APPENDIX B

OTHER CARRIER

CODE LIST

4/16/03 B.2


I1550 MERCK MEDCO

I0276 MERCK/MEDCO

I1783 MERCK/MEDCO

I1443 MERCK-MEDCO

I0907 MEREK MEDCO

AW076 MET LIFE

I1213 MMRX OF FLA

AT142 NATIONAL PRESCRIPTION ADM

I1214 NEIGHBOR CARE PHARMACY

I0262 NPA

I1158 NPA

I1778 PA BLUE SHIELD

AY653 PAID PRESCRIPTIONS

I0483 PAID PRESCRIPTIONS






I1032 PAID PRESCRIPTIONS INC

I1180 PAID PRESCRIPTIONS INC

I0954 PCS

I1364 PCS

I0899 PCS HEALTH SYSTEM

QD185 PCS HEALTH SYSTEMS INC

I1106 PD PRESCRIPTIONS INS

I1250 PHARMACARE

I0856 PREFORM

I0498 PRO VANTAGE

AR076 PRUDENTIAL

I0323 RETAIL PHARMACY PROGRAM

I0244 RX PRIME

I1272 RX PRIME CUSSTOMER SERVICE

I1789 RX WEST

I0820 SCRIPT RX

I1621 SERVICE BENEFIT PLAN

AP070 TRIGON BC AND BS

I1330 UNITED CONCORDIA

I1439 UNITED HEALTH CARE

93


AT020 UNITED HEALTHCARE

APPENDIX B

OTHER CARRIER

CODE LIST

4/16/03 B.3


I0491 VALUE RX

I0624 VALUE RX

I0824 VALUE RX

I0028 VALUE RX SERV

AY793 VALUE RX SERVICES

I1336 VSP

I1627 WELL POINT PHARMACY MANAGEMENT

88888 MEDICARE

99999 MEDICAID

APPENDIX C

MARYLAND FORMS

4/16/03 C

94


downloaded - Maryland Pharmacy Programs

Affiliated Computer Services

Pharmacy Provider

Claims Processing Manual for

Maryland Pharmacy

Programs:

Maryland Medical Assistance Program (MA)

Maryland AIDS Disease Assistance Program (MADAP)

Breast and Cervical Cancer Diagnosis and Treatment

(BCCDT)

Kidney Disease Program (KDP)

Program Specific Information

Max Days 14

Max Days 28

Max Days 90

Max Days 100

Max Days 120

Max Days 180

Prior Authorization

SmartPA

Coordinated ProDur / Mental Health Formulary

Mental Health Formulary

Abilify

Geodon

Ritalin LA

MH Drug Restrictions

Age Limitations :

LTC / Hospice Claim Billing

Emergency Fill

Generic Mandatory

Pricing

Dispensing fees

Drug Coverage

Generic Mandatory

Date Rx Written and Date of Service

Pricing

Copays

Dispensing Fee

Drug Coverage

Maintenance Drug List

Drugs Not Covered

Prior Authorization

SmartPA

Copay Only Claim Billing Guidelines

Maryland Kidney Disease Program (KDP)

Generic Mandatory and Dispense as Written Code Usage

LTC

Minimum / Maximum Quantities

Minimum Quantity

Date of Rx Written and Date of Service

Unit Dose

Pricing

Dispensing Fee

Copays

Prior Authorizations

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