Information on DHS Applications and Forms grouped by category. Ohio Medicaid Managed Care Plan Pharmacy Benefit Administrator, BIN, PCN, and Group Specialty Pharmacy name and telephone number Website address for pharmacy information Aetna Better Health CVS/ Caremark 1-855-364-2975 Medicare/Medicaid Members BIN: 610591 PCN: MEDDADV Group: RX8812 Medicaid Only Members BIN: 610591 PCN: ADV Group: RX 8810 Required if Additional Message Information (526-FQ) is used. Hospital care and services. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. This will allow the pharmacist to determine if the medication was prescribed in relation to a family planning visit (e.g., tobacco cessation, UTI and STI/STD medications). Legislation policy and planning information. The Transaction Facilitator and CMS . 06 = Patient Pay Amount (505-F5) Plan Name/Group Name: Illinois Medicaid BIN: 1784 PCN: ILPOP Processor: Change Healthcare (CHC) Effective as of: September 21, 22 NCPDP Telecommunication Standard Version/Release #: D. NCPDP Data Dictionary Version Date: July 27 NCPDP External Code List Version Date: July 213 Contact/Information Source: 1-877-782-5565 Separately, physician administered drugs must have a UD code modifier on 837P, 837I and CMS 1500 claim formats. No products in the category are Medical Assistance Program benefits. Drugs administered in the hospital are part of the hospital fee. Medicare-Medicaid Coordination Private Insurance Innovation Center Regulations & Guidance Research, Statistics, Data & Systems Outreach & Education Back to HPMS Guidance History Clarification of Unique BIN (or BIN/PCN) Requirements as of January 1, 2012 Title Clarification of Unique BIN (or BIN/PCN) Requirements as of January 1, 2012 Date var gcse = document.createElement('script'); The public may submit comments on the drugs included or not included on the Common Formulary, new drug products, prior authorization criteria, step therapy criteria and other topics related to drug coverage under the Common Formulary. The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member. Required for partial fills. M -Mandatory as defined by NCPDP R -Required as defined by the Processor RW -Situational as defined by Plan Transaction Header Segment: Mandatory Field # NCPDP Field Name Value Req Comment 11-A1 BIN Number 004336, 610591 012114, 013089 020396 Pharmacies should continue to rebill until a final resolution has been reached. See Appendix A and B for BIN/PCN combinations and usage. Pharmacy Benefit Administrator, BIN, PCN, Group, and telephone number Specialty Pharmacy name and telephone number Website address for pharmacy information Aetna Better Health CVS/ Caremark Phone: 1-855-364-2975 Medicare/Medicaid Members BIN: 610591 PCN: MEDDADV Group: RX8812 Medicaid Only Members BIN: 610591 PCN: ADV Group: RX8810 To find out if a medication is a covered pharmacy benefit, refer to the Appendix P and/or the Preferred Drug List (PDL) located on the Pharmacy Resources web page. Interactive claim submission must comply with Colorado D.0 Requirements. The following categories of members are exempt from co-pay: Effective July 1, 2022, the following changes occurred as it relates to family planning and family planning-related pharmacy benefits. Those who disenroll Prior authorization requests for some products may be approved based on medical necessity. The following NCPDP fields below will be required on 340B transactions. Single agent antihistamines and their combination products with a decongestant are not considered to be cough and cold products and are regular Medical Assistance Program benefits. Approval of a PAR does not guarantee payment. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. Required if needed to uniquely identify the family members within the Cardholder ID, as assigned by the other payer. Applicable co-pay is automatically deducted from the provider's payment during claims processing. Required if other insurance information is available for coordination of benefits. Required when the patient meets the plan-funded assistance criteria, to reduce Patient Pay Amount (505-F5). If the reconsideration is denied, the final option is to appeal the reconsideration. If a pharmacy disagrees with the final decision of the pharmacy benefit manager, the pharmacy may file an appeal with the Office of Administrative Courts. Lansing, Michigan 48909-7979, Telephone Number: 517-245-2758 NCPDP Reject 01: Invalid BIN. Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc. Fax requests are permitted for most drugs. Changes may be made to the Common Formulary based on comments received. Home to an array of public health programs, initiatives and interventions aimed at improving the health and well-being of women, infants, families and communities. Drugs administered in clinics, these must be billed by the clinic on a professional claim. Pharmacies must complete third-party information on the PCF and submit documentation from the third-party payer of payment or lack of payment. The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. These records must be maintained for at least seven (7) years. CoverMyMeds. If the appropriate numbers of days have not lapsed, the claim will be denied as a refill-too-soon unless there has been a change in the dosing. Information on adoption programs, adoption resources, locating birth parents and obtaining information from adoption records. Also effectiveJuly 1, 2021, any claims that are submitted to our legacy pharmacy processor, NCTracks, for beneficiaries enrolled in managed care plans will reject with the information necessary to process pharmacy claims for these members. This form or a prior authorization used by a health plan may be used. Provider Payments Information on the direct deposit of State of Michigan payments into a provider's bank account. Group: ACULA. Required if Ingredient Cost Paid (506-F6) is greater than zero (0). Nursing facilities must furnish IV equipment for their patients. Contact the plan provider for additional information. 07 = Amount of Co-insurance (572-4U) If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan. '//cse.google.com/cse.js?cx=' + cx; The situations designated have qualifications for usage ("Required if x", "Not required if y"). Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer. Please note, the data below is Part 4 of 6 (H5337 - H7322) with links to Parts 1 through 3 and Parts 5 and 6. Required if this field is reporting a contractually agreed upon payment. Required if needed to identify the actual cardholder or employer group, to identify appropriate group number, when available. Bank Identification Number (BIN) and Processor Control Number (PCN): For submitting FFS claims to Medicaid via NCPDP D.0, the BIN number is required in field 101-A1 and is "004740". Oregon Medicaid Pharmacy Quick Reference (effective January 2023; Updated 01/10/2023) When in doubt, refer to the Pharmaceutical Services provider guidelines at . If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. Bridge Card Participation Information on Electronic Benefits for clients and businesses, lists of participating retailers and ATMs, and QUEST. The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication. State of New York, Howard A. Zucker, M.D., J.D. The Pharmacy Carve-Out does not apply to members enrolled in Managed Long-Term Care plans (e.g., MLTC, PACE and MAP), the Essential Plan, or Child Health Plus (CHP). Providers may submit coverage exception requests by fax, phone or electronically: For BCCHP plans, fax 877-480-8130, call 1-866-202-3474 (TTY/TDD 711) or submit electronically on MyPrime or CoverMyMeds login page. Equal Opportunity, Legal Base, Laws and Reporting Welfare Fraud information. Claims that are older than 120 days are still considered timely if received within 60 days of the last denial. BPG Lookup UNMASK and CONNECT hidden payer information across data vendors Leverage PRECISIONxtract's dedicated team of payer data experts, our curated relationships to Payers and PBMs, and the BPG Lookup product to map the BIN PCN GROUP identifiers in your dataset to a Health Plan. Following are billing instructions for the Molina Healthcare Medicaid Plans: BIN: 004336, PCN: ADV GRP: RX0546, RX6422, RX6423 MediCalRx. The PDL was authorized by the NC General AssemblySession Law 2009-451, Sections 10.66(a)-(d). |Fax Number: 517-763-0142, E-mail Address: MDHHSCommonFormulary@michigan.gov, Adult & Children's Services collapsed link, Safety & Injury Prevention collapsed link, Emergency Relief: Home, Utilities & Burial, Adult Behavioral Health & Developmental Disability, https://dev.michigan.local/som/json?sc_device=json, Pre-Single PDL Changes (before October 1, 2020). Prescriber NPI will be required on all pharmacy transactions with a DOS greater than or equal to 02/25/2017. Required if Other Payer Reject Code (472-6E) is used. Enrolling in Health First Colorado as an OPR provider: If an OPR prescriber does not wish to enroll with Health First Colorado they must refer their patients to an enrolled prescriber, otherwise claims will deny. Required if utilization conflict is detected. The following lists the segments and fields in a Claim Billing or Claim Rebill response (Paid or Duplicate of Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Services cannot be withheld if the member is unable to pay the co-pay. Cost-sharing for members must not exceed 5% of their monthly household income. Please see the payer sheet grid below for more detailed requirements regarding each field. The pharmacy benefit manager reviews the claim and immediately returns a status of paid or denied for each transaction to the provider's personal computer. these fields were not required. Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. Some claim submission requirements include timely filing, eligibility requirements, pursuit of third-party resources, and required attachments included. In certain situations, you can. 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