Programs: Maryland Medical Assistance Program (MA)

Affiliated Computer Services

Pharmacy Provider

Claims Processing Manual

for

Maryland Pharmacy

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

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

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

INTRODUCTION

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.

Implementation

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.

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
   

TELEPHONE NUMBERS AND ADDRESSES

1739. 
      DME/DMA
      

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
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

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.

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

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, KDP & BCCDT CLAIM FORMAT:

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.

MA, MADAP, KDP & BCCDT Media options include POS, Direct lease line to Affiliated Computer Services, Paper, and FTP. Paper is for exceptional processing only.

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.

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)

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:

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)

Maryland Medicaid DRMDPROD

BCCDT DRBDPROD

MADAP DRMAPROD

KDP DRKDPROD
Group #:
Maryland Medicaid MDMEDICAID

KDP MARYLANDKDP

BCCDT MDBCCDT

MADAP MADAP

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:
   
   1. 
      Resubmit the claim with a valid DEA number; or
      
   2. 
      Call the ACS Call Center and request assistance in determining the Prescriber DEA number
      
   3. 
      If no valid DEA number is found, the Call Center will provide a dummy DEA number
      

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.
   

KDP Recipient Number & 5 leading zeros

BCCDT BCCDT Recipient ID

MADAP MADAP ID

(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

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.

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. 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.

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.

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

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)

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)

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

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

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) 767-1693.

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.
   

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
   

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
   

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

DAW 0

DAW 5

Accepted DAW codes for BCCDT and MADAP are:

DAW 1

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 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.

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.

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

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.

Program Specific Information

Copays

(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 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 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 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. 
   28 day supply, as identified through drug file analysis (see below)
   
4. 
   90 day supply as identified through drug file analysis (see below)
   
5. 
   100 day supply, as identified through drug file analysis (see below)
   
6. 
   120 day supply, as identified through drug file analysis (see below)
   
7. 
   180 day supply, as identified through drug file analysis (see below)