Programs: Maryland Medical Assistance Program (MA)
Download 3.34 Mb.
|
- Navigate this page:
- Max Quantity by Drug –Duragesic
- Max Quantity by Drug – Max qty = 4000
- Max Quantity by Drug – Max qty = 4050
- Max Quantity by Drug – Max qty = 120 / 34 days
- Max Quantity by Drug – Antiemetics
Max Quantity by Drug 120
Max Quantity by Drug –Duragesic
Max Quantity by Drug – Max qty = 4000
Max Quantity by Drug – Max qty = 4050
Max Quantity by Drug – Max qty = 120 / 34 days
Max Quantity by Drug – Antiemetics
Max Days 102
OTC Drug Coverage OTC drugs are generally not covered by BCCDT but there are exceptions and they are in the grid below:
MEDICARE B BCCDT will cost avoid for Medicare B covered drugs The system will deny COB claims for Medicare B recipients 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 covered by Medicare B:
Qualified Medicare Beneficiary (QMB) Recipients The system will pay coinsurance for QMB recipients if claims contain another coverage code of 3 or 4 for Med-B covered drugs only. ACS will ensure that QMB recipients 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 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"
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. Drugs not covered by Medicare D that may be covered by BCCDT. Some require prior authorization.
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 co-payments for PAC recipients if claims contain an "8" in NCPDP field 308-C8, Other Coverage Code. The system will reject PAC claims 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 Co-payments – 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.
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): 0 - default, no product selection 1 - Physician request 5 - Brand used as generic PRODUR EDITS: BCCDT 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 BCCDT 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. 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:
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||