If the medication has been determined to be family planning or family planning-related, it should be documented in the prescription record. MedImpact is the prescription drug provider for all medical Plans. Office of Health Insurance Programs, New York State Medicaid Update - December Pharmacy Carve Out: Part One Special Edition 2020 Volume 36 - Number 17, Health & Safety in the Home, Workplace & Outdoors, Clinical Guidelines, Standards & Quality of Care, All Health Care Professionals & Patient Safety, December 2020 DOH Medicaid Updates - Volume 36, Information for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Providers, Medicaid Pharmacy List of Reimbursable Drugs, Durable Medical Equipment, Prosthetics and Supplies Manual, Transition and Communications Activities Timeline document, Attention: Pharmacies Durable Medical Equipment, Prosthetics, Orthotics, and Supply Providers, and Prescribers That are Not Enrolled in Medicaid Fee-for-Service, NYS Pharmacy Benefit Information Center website, Pharmacy Carve-Out and Frequently Asked Questions (FAQs), Supplies Covered Under the Pharmacy Benefit, Medicaid Preferred Diabetic Supply Program, NYS Medicaid Program Pharmacists As Immunizers Fact Sheet, James V. McDonald, M.D., M.P.H., Acting Commissioner, Multisystem Inflammatory Syndrome in Children (MIS-C), Addressing the Opioid Epidemic in New York State, Health Care and Mental Hygiene Worker Bonus Program, Maternal Mortality & Disparate Racial Outcomes, Help Increasing the Text Size in Your Web Browser, Covered outpatient prescription and over-the-counter (OTC) drugs that are listed on the, Pharmacist administered vaccines and supplies listed in the. Michigan's Women, Infants & Children program, providing supplemental nutrition, breastfeeding information, and other resources for healthy mothers & babies. Use BIN Number 61499 for all claims except ADAP claims. The pharmacy benefit manager processes both electronic and paper claims and provides claim, provider, eligibility, and PAR interfaces with the Medicaid Management Information System (MMIS). These medications (e.g., Paxlovid) still need to be billed to Colorado Medicaid, even though they are free of cost, and the claim requirements for billing free medications is outlined below: The Health First Colorado program uses the National Council on Prescription Drug Programs (NCPDP) electronic format and the Pharmacy Claim Form (PCF) to submit prescription drug claims. Information on Safe Sleep for your baby, how to protect your baby's life. UnitedHealthcare Medicaid Plans: 877-305-8952 All other Plans: 800-788-7871 Other versions supported: ONLY D.0 . Updated Lost/Stolen/Damaged/Vacation Prescriptions section - police report is no longer required for Stolen Medications, PAR Process: Updated notification letter section, Partial Fills and/or Prescription: Updated partial fill criteria, Updated contact information on page 15, to include Magellan's helpdesk info. Pharmacies may call the Pharmacy Support Center to request a quantity limit override if the medication is related to the treatment or prevention of COVID-19, or the treatment of a condition that may seriously complicate the treatment of COVID-19. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). money from Medicare into the account. Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. Unless otherwise communicated in the PDL or Appendix P, maintenance medications may be filled for up to a 100-day supply, and non-maintenance medications may be filled for up to a 30-day supply. Sent when Other Health Insurance (OHI) is encountered during claims processing. *Note: Code 09 is a negative amount and is not a valid option for field 351-NP. Medicaid Pharmacy . The CIN is located on all member cards including MMC plan cards. New PAs and existing PA approvals that are less than 12 months are not eligible for deferment. during the calendar year will owe a portion of the account deposit back to the plan. TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult. Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. Personal care items such as mouth wash, deodorants, talcum powder, bath powder, soap (of any kind), dentifrices, etc. Please Note: Physician administered (J-Code) drugs that are not listed on the Medicaid Pharmacy List of Reimbursable Drugs and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) as listed in sections 4.4, 4.5, 4.6, and 4.7 of the Durable Medical Equipment, Prosthetics and Supplies Manual are not subject to the carve-out. New York State Department of Health, Donna Frescatore
COVID-19 early refill overrides are not available for mail-order pharmacies. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. 20 = 340B - Indicates that, prior to providing service, the pharmacy has determined the product being billed is purchased pursuant to rights available under Section 340B of the Public Health Act of 1992 including sub-ceiling purchases authorized by Section 340B (a) (10) and those made through the Prime Vendor Program (Section 340B(a)(8)). If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. Requests for Reconsideration must be filed in writing with the pharmacy benefit manager within 60 days of the most recent claim or prior reconsideration denial. Secure websites use HTTPS certificates. Prescription cough and cold products for all ages will not require prior authorization for Health First Colorado members. It is recommended that pharmacies contact the Pharmacy Support Center before submitting a request for reconsideration. Cheratussin AC, Virtussin AC). Universal caseload, or task-based processing, is a different way of handling public assistance cases. 2.1 Application, Determination of Eligibility and Furnishing Medicaid 2.2 Coverage and Conditions of Eligibility 2.3 Residence 2.4 Blindness 2.5 Disability 2.6 Financial Eligibility 2.7 Medicaid Furnished Out of State 3.0 SERVICES: GENERAL PROVISIONS 3.1 Amount, Duration, and Scope of Services 3.2 Coordination of Medicaid with Medicare Part B Prescribers may continue to write prescriptions for drugs not on the PDL. In addition, some products are excluded from coverage and are listed in the Restricted Products section. Does not obligate you to see Health First Colorado members. Please contact the plan for further details. The Michigan Domestic & Sexual Violence Prevention and Treatment Board administers state and federal funding for domestic violence shelters and advocacy services, develops and recommends policy, and develops and provides technical assistance and training. Required if needed by receiver to match the claim that is being reversed. false false Insertion sort: Split the input into item 1 (which might not be the smallest) and all the rest of the list. P.O. A federal program which helps persons admitted into the U.S. as refugees to become self-sufficient after their arrival. If a member requires a refill before 50% of the day supply has lapsed, please provide the Pharmacy Support Center details of the extenuating circumstances. Information on resources in your community and volunteer recruitment and training, and services provided at local DHS offices. The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website. The BIN/IIN field will either be filled with the ISO/IEC 7812 IIN or the NCPDP Processor BIN, depending on which one the health plan has obtained. The Department does not pay for early refills when needed for a vacation supply. 01 = Amount Applied to Periodic Deductible (517-FH), 02 = Amount Attributed to ProductSelection/Brand Drug (134-UK), 03 = Amount Attributed to Sales Tax(523-FN), 04 = Amount Exceeding Periodic Benefit Maximum (520-FK), 06 = Patient Pay Amount (Deductible) (505-F5), 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection(135-UM), 10 = Amount Attributed to Provider Network Selection (133-UJ), 11 = Amount Attributed to Product Selection/Brand Non-Preferred FormularySelection(136-UN), 12 = Amount Attributed to Coverage Gap (137-UP), 13 = Amount Attributed to Processor Fee (571-NZ), MA = Medication Administration - use for vaccine. Author: jessica.jump Created Date: The CSHCN Services Program is a separate program from Medicaid and has separate funding sources. Required if Other Payer Amount Paid Qualifier (342-HC) is used. For more information on the drug benefit for people not enrolled in a health plan (Fee-for-Service Medicaid) visithttps://michigan.magellanrx.com. Please contact the Pharmacy Support Center for a one-time PA deferment. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. })(); Chart of 2022 BIN and PCN values for each Medicare Part D prescription drug plan Part 4 of 6 (H5337 through H7322). Mail: Medi-Cal Rx Customer Service Center, Attn: PA Request, PO Box 730, Sacramento, CA 95741-0730. Hospital care and services. Payer/Carrier BIN/PCN Date Available Vendor Certification ID 4D d/b/a Medtipster 610209/05460000 Current 601DN30Y Adjudicated Marketing 600428/05080000 Current 601DN30Y Alaska Medicaid 009661 Current 091511D002 AHCCCS FFS and MCO Contractors BIN, PCN and Group ID's effective 1/1/2022; Tamper Resistant Prescription Pads Memo 11/08/2012 | Rich Text Version & 04/27/2012 | Rich Text . Product may require PAR based on brand-name coverage. ", 00 = If claim is a multi-ingredient compound transaction, Required - If claim is for a compound prescription, enter "00.". Required if Patient Pay Amount (505-F5) includes deductible. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. In order to participate in the Discount . The Prior Authorization criteria for drugs indicated on the Medicaid Health Plan Common Formulary as requiring PA is below: A standard prior authorization form, FIS 2288, was created by the Michigan Department of Insurance and Financial Services (DIFS) to simplify the process of requesting prior authorization for prescription drugs. Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. Pharmacy Billing Procedures and Forms section of the Department's website, NCPDP Uu~Daw 0 Cannot Be Submitted Ms Drug W/Avail Generics~50740~Error List Daw0 Cant Be Submit Ms Drug W/Avail Gen. Prescriber has indicated the brand name drug is medically necessary. Mental illness as defined in C.R.S 10-16-104 (5.5). Values other than 0, 1, 08 and 09 will deny. Update to URL posted under Pharmacy Requirements and Benefits sections per Cathy T. request. DESI drugs and any drug if by its generic makeup and route of administration, it is identical, related, or similar to a less than effective drug identified by the FDA, Drugs classified by the U.S.D.H.H.S. . A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. 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 Health plans usually only cover drugs (brand and generic) that are on this "preferred" list. All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. May be used for cases where Health First Colorado's drug list designates both a brand drug and its generic equivalent as non-preferred products and also designates that the non-preferred brand product is favored for coverage over the equivalent non-preferred generic. the Medicaid card. the processor specifies in writing that a commercial BIN and blank PCN is solely for plans Supplemental to Part D, or. Each PA may be extended one time for 90 days. This webpageis designed toprovide easy access for members and providers looking for information on the drugs and supplies covered by Michigan Medicaid Health Plans. This number is used by the pharmacy to submit pharmacy claims to Medicaid FFS. Medicaid Publication Date June 1, 2021 BIN(s) 023880 PCN(s) KYPROD1 Processor MedImpact Healthcare Systems, Inc. Primary Care ACOs PBM BIN PCN Group Pharmacy Help Desk Community Care Cooperative (C3) Conduent 009555 MASSPROD MassHealth (866) 246-8503 . Drugs administered in clinics, these must be billed by the clinic on a professional claim. Required on all COB claims with Other Coverage Code of 2. Required to identify the actual group that was used when multiple group coverage exist. Required when additional text is needed for clarification or detail. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins. Claims that cannot be submitted through the vendor must be submitted on paper. For all other information as it relates to family planning benefits, please visit the Maternal, Child and Reproductive Health billing manual web page. Prescribers may either switch members to a preferred product or may obtain a PA for a non-preferred product. Information on Adult Protective Services, Independent Living Services, Adult Community Placement Services, and HIV/AIDS Support Services. Bureau of Medicaid Care Management & Customer Service Completed PA forms should be sent to (800)2682990 . Health First Colorado is temporarily deferring medication prior authorization (PA) requirements for members on all medications for which there is an existing 12-month PA approval in place. The Bank Information Number (BIN) (Field 11A1) will change to "6184" for all claims. When timely filing expires due to delays in receiving third-party payment or denial documentation, the pharmacy benefit manager is authorized to consider the claim as timely if received within 60 days from the date of the third-party payment or denial or within 365 days of the date of service, whichever occurs first. Health Care Coverage information and resources. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. area. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. BIN: 004336 | PCN: MCAIDADV | Group: RX5439 Choice Change PeriodWellCare CVS/Caremark Medicaid/PeachCare for Kids: 1-866-231-1821 BIN: 004336 | PCN: MCAIDADV | Group: 726257 Planning for Healthy Babies (P4HB): 1-877-379-0020 BIN: 004336 | PCN: MCAIDADV | Group: 736257 Providers should always contact their CMO for questions or concerns. These source documents, in addition to any work papers and records used to create electronic media claims, shall be retained by the provider for seven years and shall be made readily available and produced upon request of the Secretary of the Department of Health and Human Services, the Department, and the Medicaid Fraud Control Unit and their authorized agents. Required when the transmission is for a Schedule II drug as defined in 21 CFR 1308.12 and per CMS-0055-F (Compliance Date 9/21/2020.) The situations designated have qualifications for usage ("Required if x", "Not required if y"). Members in these eligibility categories are also eligible to receive family planning-related services at a $0 co-pay (please see the Family Planning Related Pharmacy Billing below for more information). Requests for timely filing waivers for extenuating circumstances must be made in writing and must contain a detailed description of the circumstance that was beyond the control of the pharmacy. 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. Drugs manufactured by pharmaceutical companies not participating in the Colorado Medicaid Drug Rebate Program. Medi-Cal Rx Provider Portal. BIN: 610084 PCN: DRMTUA01 = Test (after 1/1/2012) Processor: Conduent Effective as of: June 1, 2017 NCPDP Telecommunication Standard Version/Release D. 0 NCPDP Data Dictionary Version Date: April 2017 NCPDP External Code List Version Date: April 2017 Updated: March 23, 2021 - - Provider Relations: (800) 365-4944 - - However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service Information on the Safe Delivery Program, laws, and publications.