Programs: Maryland Medical Assistance Program (MA)
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Affiliated Computer Services Pharmacy Provider Claims Processing Manual For Maryland Pharmacy Programs: Maryland Medical Assistance Program (MA) Maryland AIDS Drug Assistance Program (MADAP) Breast and Cervical Cancer Diagnosis and Treatment Program (BCCDT) Kidney Disease Program (KDP) Administered By: Affiliated Computer Services, Inc Government Healthcare Solutions Revised 4/03/2007 TABLE OF CONTENTS
APPENDICES APPENDIX A PAYER SPECIFICATION SHEET 138 APPENDIX B 179 OTHER CARRIER CODE LIST SECTION I INTRODUCTION Maryland Medicaid (MA), Breast and Cervical Cancer Diagnosis and Treatment Program (BCCDT), Kidney Disease Program (KDP) and Maryland AIDS Drug Assistance Program (MADAP) 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 Authorizations using our SmartPA technology, and prospective drug utilization review (ProDUR) across all network pharmacies. Pharmacy providers must be enrolled in the pharmacy program they are billing 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: (800) 932-3918 AFFILIATED COMPUTER SERVICES, INC. looks forward to working with you to ensure the success of the Maryland Medicaid (MA), Breast and Cervical Cancer Diagnosis and Treatment Program (BCCDT), Kidney Disease Program (KDP) and Maryland AIDS Drug Assistance Program (MADAP). SECTION II IMPLEMENTATION
Non-waiver eligible Medical Assistance recipients in long-term care facilities; Specialty Mental Health drugs for waiver and non-waiver eligible Medical Assistance recipients; Other drugs as determined by the Department for waiver eligible medical assistance recipients; PAC Program recipients; Kidney Disease Program recipients; Maryland AIDS Drug Assistance Program recipients; Breast and Cervical Cancer Diagnosis and Treatment Program recipients; and, Other recipients as determined by the Department SECTION III MARYLAND PHARMACY PROGRAMS TELEPHONE NUMBERS
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. SECTION IV 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: (800) 932-3918 SECTION V PROGRAM SET-UP
MA, MADAP, KDP & BCCDT 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 Pharmacy programs The paper claim format for MADAP is Maryland’s proprietary form on the website. Not all programs accept Paper Claims – see later information for program specifics 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 and B 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) 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 and B. IDENTIFICATION NUMBERS: BIN #: 610084 – ALL PROGRAMS 610084 (Coordinated ProDUR)
BCCDT DRDTPROD MADAP DRAPPROD KDP DRKDPROD Group #: Maryland Medicaid MDMEDICAID KDP MDKDP BCCDT MDBCCDT MADAP MADAP Maryland Pharmacy Programs BIN/PCN/Group ID combinations Under ACS
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:
Cardholder ID #: The system will ensure each recipient has his/her own identification number depending on which program they belong to (i.e. – MADAP, BCCDT, 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: Claims cannot be submitted with the mother’s ID. 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. Maryland Medicaid MD Medicaid 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:
Original claims (NCPDP transaction B1) 279 days Reversal and Re-bill claims (NCPDP transactions B2 and B3) 279 days
Requests for timely filing limit overrides should be directed to Maryland Medical Assistance at (410) 767-6028.
Original claims (NCPDP transaction B1) 183 days 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. BCCDT Timely Filing Limits: Original claims, reversals, and adjustments ( B1, B2, B3) 279 days For BCCDT call 410-767-6787
Original claims, reversals, and adjustments: (B1, B2, B3) 279 days 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 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.
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. 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. SECTION VI COORDINATION OF BENEFITS (COB)
If MA, MADAP, BCCDT & KDP is the patient’s secondary carrier; claims for COB (coordination of benefits) will be accepted. MA, MADAP, BCCDT & KDP 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 AFFLIATED COMPUTER SERVICES, INC 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 system calculated “Allowed Amount” when calculating payment. Note: In some cases, this may result in a ‘0’ payment. 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, KDP, and MADAP recipients. The process and required fields are outlined in each individual section of this manual SECTION VII MARYLAND MEDICAID PROGRAM SPECIFICS
Maryland Medicaid will deny for Therapeutic Duplication (TD) and Early Refill (ER) only. Alert messages will be returned for other ProDUR problem types. 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.: 1-800-932-3918. 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. 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; it 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 Coordinated ProDUR editing is “message only” (i.e. no denials). MULTI-LINE COMPOUND CLAIM SUBMISSION Maryland Medicaid will accept 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.
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) 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: Oral contraceptives = 180 day supply 14 day supply, as identified through drug file analysis (see below) 28 day supply, as identified through drug file analysis (see below) 90 day supply as identified through drug file analysis (see below) 100 day supply, as identified through drug file analysis (see below) 120 day supply, as identified through drug file analysis (see below) 180 day supply, as identified through drug file analysis (see below) Directory: docs -> common docs -> Application for acem docs -> Observational Assessment of Teaching Practices Teaching Assessment Initiative Proposal Submitted to The Teachers for a New Era project docs -> Traditional British values docs -> From Warfighters to Crimefighters: The Origins of Domestic Police Militarization docs -> Borzoi Club of America Register of Merit Program I. What is a Register Of Merit docs -> Protecting the rights of the child in the context of migration docs -> United Nations E/C. 12/Esp/5 docs -> 9th May 1950 the schuman declaration docs -> Getting To Outcomes® in Services for Homeless Veterans 10 Steps for Achieving Accountability common -> Programs: Maryland Medical Assistance Program (MA) Download 3.34 Mb. Share with your friends:
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