Pharmacy Claims Processing Manual

Transcription

1 Pharmacy Claims Processing Manual for the Michigan Department of Community Health Medicaid Adult Benefits Waiver (ABW) Children s Special Health Care Services (CSHCS) Maternity Outpatient Medical Services (MOM) Version 1.1 August 8, 2006

2 Notice of Copyright The following presented information is confidential and proprietary and is intended for the express use of and authorized clients. Any unauthorized use of this material is prohibited and punishable by law. All material is copyright 2005, HIPAA Privacy Rules The Health Insurance Portability and Accountability Act of 1996 (HIPAA Public Law ) provides, among other things, strong protection for personal health information. It gives individuals certain rights concerning their health information, sets boundaries on how it is used, establishes formal safeguards, and holds violators accountable. The HIPAA Privacy regulations give the individual the right to control his own identifiable health information even when it is created and maintained by others. The regulations went into effect on April 14, Protected health information (PHI) includes any health information whether verbal, written, or electronic, that is created, received, or maintained by First Health. It is health care data plus identifying information that allows someone using the data to tie the medical information to a particular person. PHI relates to the past, present, and future physical or mental health of any individual or recipient; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual. Claims data, prior authorization information, and attachments such as medical records and consent forms are all PHI. PHI may not be released to anyone who is not authorized to receive the information or who does not have a need to know that information. Information released will be the minimum necessary to achieve the stated goal unless the member releases the information, the information is required by law, or is necessary for treatment. Authorization is always required for any use or disclosure of PHI that is not permitted under the privacy regulations. To avoid interfering with an individual s access to quality health care or the efficient payment for such health care, the privacy rule permits a covered entity to use and disclose PHI, with certain limits and protections, for treatment, payment, and health care operations activities. It also permits covered entities to disclose PHI without authorization for certain public health and workers compensation purposes, and other specifically identified activities. Please refer to the final privacy rule published in the Federal Register on December 28, 2000, for regulatory details about permitted uses and disclosures of PHI. Page 2

3 Revision History Document Version 1.0 6/26/06 Date Name Comments First updated version since 5.1 version effective August 14, /08/06 Maintenance Drug List was updated, and the Payer Specifications was changed to reflect that MIC will be implemented at an undetermined future date. Page 3

4 Table of Contents Notice of Copyright... 2 HIPAA Privacy Rules... 2 Revision History... 3 Table of Contents Introduction MDCH Pharmacy Programs Pharmacy Benefit Manager - First Health Services Billing Overview and Background Enrolling as a MDCH-Approved Pharmacy Claim Formats and MDCH - Specific Values First Health Services Website for MDCH Important Contact Information First Health Services Call Centers Technical Call Center Clinical Call Center Beneficiary Help Line Program Setup Claim Format Point-of-Sale - NCPDP Version Supported POS Transaction Types Required Data Elements NCPDP Batch Format Paper Claim - Universal Claim Form (UCF) Service Support Online Certification Electronic Funds Transfer (EFT) Electronic Remittance Advice Solving Technical Problems Online Claims Processing Edits Program Specifications Timely Filing Limits Overrides Days Supply and Maintenance Drug List Schedule II Refills Retail Schedule II Prescriptions Schedule II Prescriptions for Individuals in Long-Term Care Facilities or Beneficiaries with a Terminal Illness Maximum Allowable Cost (MAC) Rates MAC Overrides Prior Authorization (PA) Special Eligibility Situations Newborns Lock-In Beneficiaries Retroactive Eligibility Page 4

5 7.7 Managed Care Plans and Pharmacy Carve-Out Lists Pharmacy Carve-Outs Michigan Medicaid Health Plan Carve-Outs Adult Benefits Waiver (ABW) County Health Plan Carve-Out Compound Claims Exceptions Requiring Universal Claim Form (UCF) Submission Home Infusion Therapy Claims Unit Dose Claims Medical Supplies and Pre-Filled Syringes Coordination of Benefits (COB) COB General Instructions Identifying Other Insurance Coverage Third Party Liability (TPL) Processing Grid First Health Services COB Processing The MDCH Pharmaceutical Product List (MPPL) & COB Special Instructions for Medicare Part B and Part D Identifying Individuals Enrolled in Medicare Medicare Part B Medicare Part D Appendix A: Payer Specifications for NCPDP B1 (Billing) and B3 (Re-Bill) Transactions B2 Transaction - Reversals Appendix B: Universal Claim Form, Version Appendix C: MDCH Maintenance Drug List Appendix D: Medicare Part B Covered Drugs Appendix E: ProDUR E.1 ProDUR Problem Types E.2 Drug Utilization Review (DUR) s E.3 DUR Reason For Service E.4 DUR Professional Service E.5 DUR Result of Service E.6 Prospective Drug Utilization Review (ProDUR) E.7 Drug/Drug Interactions & Therapeutic Duplication E.7.1 POS Override Procedure E.7.2 DUR Reason for Service Appendix F: POS Reject Codes & Messages F.1 Prospective Drug Utilization Review (ProDUR) Alerts F.2 Point-of-Sale Reject Codes and Messages Appendix G: Directory Page 5

6 1.0 Introduction 1.1 MDCH Pharmacy Programs This manual provides claims submission guidelines for the following fee-for-service pharmacy programs administered by the Michigan Department of Community Health (MDCH). Medicaid Adult Benefits Waiver (ABW) Children s Special Health Care Services (CSHCS) Maternity Outpatient Medical Services (MOMS) Billing guidelines specified throughout this manual pertain to all programs, as do any references to Medicaid/MDCH, unless specifically stated otherwise. Important MDCH coverage and reimbursement policies are available in the Michigan Medicaid Provider Manual and the Michigan Pharmaceutical Product List (MPPL). The (FHSC) website for MDCH contains a link to these documents. 1.2 Pharmacy Benefit Manager - First Health Services MDCH contracts with (FHSC) as its pharmacy benefit manager to: Adjudicate claims Distribute payment and remittance advices (RA) Enroll pharmacies as approved MDCH pharmacy providers Review prior authorization requests Perform prospective Drug Utilization Review (ProDUR) and Retrospective Drug Utilization Review (RetroDUR) Conduct post-payment audits Provide clinical consultation Page 6

7 2.0 Billing Overview and Background 2.1 Enrolling as a MDCH-Approved Pharmacy To enroll as a Medicaid pharmacy provider, the pharmacy must complete the Pharmacy Provider Enrollment & Trading Partner Agreement, MSA-1626 (03-05). When applying for enrollment, pharmacies that serve nursing facility beneficiaries can also request reimbursement for repacking medication into unit dose by completing the Unit Dose Pharmacy Agreement, MSA-0590 (Rev. 3-05). Both forms are available at First Health Services website at Select the link to Provider and then Provider Forms. Completed applications, questions on enrollment status, and updates to pharmacy enrollment information should be directed to First Health Services. Refer to the Provider Relations Department in the Appendix G: Directory at the end of this manual for contact information. 2.2 Claim Formats and MDCH - Specific Values Pharmacy claims may be submitted online by Point-Of-Sale (POS), by batch media, or paper using the following National Council for Prescription Drug Programs (NCPDP) standards: POS: NCPDP version 5.1 Batch: NCPDP Batch 1.1 Paper: Universal Claim Form (UCF) Refer to Section Claim Format for further details on acceptable claim formats and specifications. Page 7

8 2.3 First Health Services Website for MDCH Announcements, provider forms, drug information, provider manuals, bulletins, and the Michigan Pharmaceutical Product List (MPPL) specifying covered drugs are posted on the First Health Services website at The following information can also be found: Michigan Medicaid Provider Manual link provides coverage, limitations, and reimbursement information. The MDCH Carrier ID Listing link identifies other insurance carrier names and addresses. 2.4 Important Contact Information Refer to Appendix G: Directory at the end of this manual for important phone numbers, mailing addresses, and websites. Page 8

9 3.0 First Health Services Call Centers First Health Services has both a Technical and Clinical Call Center to assist pharmacists and prescribers as well as a Beneficiary Help Line that offers assistance to beneficiaries. The Appendix G: Directory at the end of this manual lists their phone numbers along with the hours of operation. 3.1 Technical Call Center (Nationwide Toll-Free Number) First Health Services provides a toll-free number for pharmacies available 7 days a week, 24 hours a day, and 365 days a year. The Technical Call Center responds to questions on coverage, claims processing, and beneficiary eligibility. Examples of issues addressed by Technical Call Center staff include, but are not limited to, the following: Early Refills - Pharmacies may contact the Technical Call Center for approval of early refills of a prescription. Questions on Claims Processing Messages - If a pharmacy needs assistance with alert or denial messages, it is important to contact the Technical Center at the time of dispensing drugs. First Health Services staff is able to provide claim information on all error messages, including messaging from the ProDUR system. Information includes the National Drug Codes (NDCs), drug names, the dates of service, the days supply, and the NCPDP number of pharmacies receiving the ProDUR message(s). Clinical Issues - 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. However, a second level of assistance is available if a pharmacist s question requires a clinical response. To address these situations, First Health Services pharmacists are available for consultation. First Health Services uses reasonable care to accurately compile its ProDUR information. Since each clinical situation is unique, this information is intended for pharmacists to use at their own discretion in the drug therapy management of their patients. Page 9

10 3.2 Clinical Call Center (Nationwide Toll Free Number) First Health Services provides a toll-free Clinical Call Center, available business days: Monday through Friday from 7:00 a.m. to 7:00 p.m. (with backup by the Technical Call Center for other hours). When prior authorization requests are denied, Clinical Call Center staff will mail notices of adverse action to the affected beneficiaries. Examples of issues addressed by Clinical Call Center staff include, but are not limited to, the following: Prescribers - The Clinical Call Center handles prior authorization requests for nonpreferred drugs, quantity limit overrides, and other situations. A pharmacy technician initially responds to callers. Requests not meeting established criteria or requiring an in-depth review are forwarded to a First Health Services pharmacist. Pharmacies - The Clinical Call Center reviews requests for coinsurance payments on drugs normally covered by Medicare Part B and drug quantity limitations The MDCH approved manufacturer list is the same as the federal list found at: The MDCH Pharmaceutical Product List (MPPL), specifying covered drugs, is available at Beneficiary Help Line (Nationwide Toll Free Number) Beneficiaries with questions about their MDCH pharmacy coverage may contact the First Health Services Beneficiary Help Line. This line is available 7 days a week, 24 hours a day, and 365 days a year. When questions are received about MDCH eligibility, First Health Services will refer beneficiaries to the MDCH Beneficiary Help Line. The MDCH Beneficiary Help Line is available at For individuals dually enrolled in Medicaid and Medicare (the duals), beneficiaries should be directed to Medicare or to the help desk of their enrolled Medicare Part D prescription drug plan. Page 10

11 4.0 Program Setup 4.1 Claim Format While First Health Services strongly recommends claims submission by POS, batch submission, and paper claims may be required for certain billings outside the norm. The following three Health Insurance Portability and Accountability Act (HIPAA) formats are accepted. Each is explained in subsequent sections. Table 1 - Claim Formats Accepted by First Health Services Billing Media NCPDP Version Comments POS Version 5.1 Online POS is preferred. Batch Batch 1.1 FTP is the preferred batch media. Paper Claim Universal Claim Form (5.1 UCF) 4.2 Point-of-Sale - NCPDP Version 5.1 First Health Services uses an online POS system that allows enrolled pharmacies real-time online access to: Beneficiary eligibility Drug coverage Pricing Payment information ProDUR The POS system is used in conjunction with a pharmacy s in-house operating system. While there are a variety of different pharmacy operating systems, the information contained in this manual specifies only the response messages related to the interactions with the First Health Services online system and not the technical operation of a pharmacy s in-house-specific system. Pharmacies should check with their software vendors to ensure their system is able to process the payer specifications listed in Appendix A: Payer Specifications for NCPDP 5.1 of this manual Supported POS Transaction Types First Health Services has implemented the following NCPDP-version 5.1 transaction types. A pharmacy s ability to use these transaction types will depend on its software. At a minimum, pharmacies should have the capability to submit original claims (B1), reversals (B2) and re-bills Page 11

12 (B3). Other transactions listed on Table 2 (although not currently used) may be available at a future date. Full Claims Adjudication (B1) - This transaction captures and processes the claim and returns the dollar amount allowed under the program s reimbursement formula. The B1 transaction will be the prevalent transaction used by pharmacies. Claims Reversal (Code B2) - This transaction is used by a pharmacy to cancel a claim that was previously processed. To submit a reversal, a pharmacy must void a claim that has received a PAID status and select the REVERSAL (Void) option in its computer system. Claims Re-Bill (Code B3) - This transaction is used by the pharmacy to adjust and resubmit a claim that has received a PAID status. A claim re-bill voids the original claim and resubmits the claim within a single transaction. The B3 claim is identical in format to the B1 claim with the only difference being that the transaction code (field 103) is equal to B3. The following fields must match the original paid claim for a successful transmission of a B2 (Reversal) or B3 (Re-Bill): Service Provider ID - NCPDP Provider Number Prescription Number Date of Service (Date Filled) Table 2 - NCPDP Version 5.1 Transaction Types Used For MDCH Pharmacy Programs NCPDP 5.1 Transaction Code Transaction Name MDCH Transaction Support Requirements E1 Eligibility Verification May be required at a future date. B1 Billing Required. B2 Reversal Required. B3 Re-Bill Required. P1 Prior Authorization Request & Billing May be required at a future date. P3 Prior Authorization Inquiry May be required at a future date. P2 Prior Authorization Reversal May be required at a future date. P4 Prior Authorization Request Only May be required at a future date. N1 Information Reporting May be required at a future date. N2 Information Reporting Reversal May be required at a future date. N3 Information Reporting Re-Bill May be required at a future date. C1 Controlled Substance Reporting May be required at a future date. Page 12

13 NCPDP 5.1 Transaction Code Transaction Name MDCH Transaction Support Requirements C2 Controlled Substance Reversal May be required at a future date. C3 Controlled Substance Reporting Re-Bill May be required at a future date Required Data Elements A software vendor will need the First Health Services payer specifications to set up a pharmacy s computer system, to allow access to the required fields, and to process claims. The First Health Services claims processing system has program-specific field requirements, e.g., mandatory, situational, and not sent. Table 3 lists abbreviations and that are used throughout the payer specifications to depict field requirements. Table 3 - Definitions of Requirement Indicators Used in Payer Specifications M R NS S O R*** Code MANDATORY Description s with this designation according to NCPDP standards must be sent if the segment is required for the transaction. REQUIRED s with this designation according to this program s specifications must be sent if the segment is required for the transaction. NOT SUPPORTED s with this designation according to this program s specifications will be ignored if sent and in some cases, result in denials. SITUATIONAL It is necessary to send these fields in noted situations. Some fields designated as situational by NCPDP may be required for all transactions. OPTIONAL s with this designation may be sent. REPEATING The R*** indicates that the field is repeating. One of the other designators, M or S will precede it. MDCH claims will not be processed without all the required (or mandatory) data elements. Required (or mandatory) fields may or may not be used in the adjudication process. Also, fields not required at this time may be required at a future date. Page 13

14 Required Segments - The three transaction types implemented by First Health Services have NCPDP-defined request formats or segments. Table 4 lists NCPDP segments used. Table 4 - Segments Supported For B1, B2, & B3 Transaction Types Segment Transaction Type Codes B1 B2 B3 Header M M M Patient M M M Insurance M O M Claim M M M Pharmacy Provider O O O Prescriber M O M COB/Other Payments S O S Worker's Comp O O O DUR/PPS S O S Pricing M M M Coupon O O O Compound S O S Prior Authorization O O O Clinical O O O Trailer M M M M = Mandatory R = Required S = Situational O = Optional Payer Specifications - A list of transaction types and their field requirements is available in the Appendix A: Payer Specifications for NCPDP 5.1. These specifications list B1, B2, and B3 transaction types with their segments, fields, field requirement indicators (mandatory, situational, optional), and values supported by First Health Services. MDCH Program Setup - Table 5 lists required values unique to MDCH programs. Page 14

15 ANSI BIN # Table 5 - Important Required Values for MDCH Program Setup s Description Comments Processor Control # Group # ØØ9737 PØØ MIMEDICAID Provider ID # NCPDP (NABP) Number 7-digit, all numeric Cardholder ID # Prescriber ID # Michigan Beneficiary ID Number Drug Enforcement Administration (DEA) Number for the Prescriber 10-digit Medicaid Health Insurance Number (2 zeros in front of the 8- digit Beneficiary ID) 9-characters Product Code National Drug Code (NDC) 11-digits If a prescriber does not have a DEA number, pharmacies must use ZZ for non-controlled substances only. ZZ will not be allowed for scheduled controlled substances. 4.3 NCPDP Batch Format 1.1 Pharmacies using batch processing primarily use File Transfer Protocol (FTP) transmissions. For record specifications and transmission requirements, pharmacies should contact the First Health Services Electronic Media Claims Coordinator for FTP and the Technical Call Center for other media types. Refer to Appendix G: Directory at the end of this manual for contacts information and for mailing addresses for batch media. 4.4 Paper Claim - Universal Claim Form (UCF) All paper pharmacy claims must be submitted to First Health Services on a Universal Claim Form (UCF) which may be obtained from a pharmacy s wholesaler. The Appendix G: Directory at the end of this manual specifies: An alternative source for obtaining UCFs and The First Health Services address that pharmacies must use when sending completed UCF billings. Completion instructions for the UCF are listed in Appendix B: Universal Claim Form, Version 5.1. For certain billings outside the norm, First Health Services may require or accept UCF submissions. Page 15

16 Examples of claims that require a UCF include, but are not limited to, the following: Compound Prescriptions - Claim payments require a submission of paper claims for compound prescriptions when: The lower of Usual and Customary or Gross Amount Due exceeds $250.00, or Compounds are for capsules or suppositories, and The pharmacy is billing for the applicable compound fee. Prescriptions Exceeding the Timely Filing Limit - Paper claims are allowed when the timely filing limit is exceeded. It is the pharmacy s responsibility to obtain an authorization override prior to submitting the paper claims. Paper claims requiring authorization overrides that are submitted without the pharmacy first obtaining the authorization override, will be returned to the pharmacy without being processed. Other Exceptions for Adult Benefits Waiver (ABW) and Maternity Outpatient Medical Services (MOMS) - First Health Services will accept paper claims if a pharmacy is unable to process a claim electronically because a beneficiary s eligibility record has not been updated. For these situations, paper claims received from the pharmacy should document that eligibility verification problems exist or provide documentation, such as the MOMS Guarantee of Payment Letter to show proof of eligibility. If within 30 days from the date the claim was received by First Health Services, the beneficiary s eligibility has not been loaded in the First Health Services system, First Health Services will forward the claim and supporting documentation to MDCH for review and resolution. Page 16

17 5.0 Service Support 5.1 Online Certification The Software Vendor/Certification Number (NCPDP #110-AK) of the Transaction Header Segment is required for claim submission under NCPDP version 5.1. First Health Services certifies software vendors, not an individual pharmacy s computer system. A pharmacy should contact its vendor or First Health Services to determine if the required certification has been obtained. For assistance with software vendor certification, contact First Health Services at [email protected]. Refer to Appendix G: Directory at the end of this manual for other contact information. 5.2 Electronic Funds Transfer (EFT) First Health Services provides an EFT payment option. To request EFT, a pharmacy must complete the Electronic Transfer Authorization Form available at Select the link to Providers and then Provider Forms. The completed form must be returned to the First Health Services Provider Relations Department. Refer to Appendix G: Directory at the end of this manual for contact information. EFT payments will begin no sooner than 16 days after receipt of the completed form. Payments will be transferred to the pharmacy s designated banking account every Monday and will be available within 24 to 48 hours. In the event that an EFT fails, First Health Services will reissue a paper check within 10 business days of the original settlement. A pharmacy may contact the First Health Services Provider Relations Department to (1) update name, address, financial institution, and account information or (2) discontinue EFT payments. 5.3 Electronic Remittance Advice First Health Services accommodates the HIPAA ANSI X12 835, version 4010A1, for remittance advices. This format replaces the proprietary electronic version previously used. First Health Services requires any entity (including pharmacies and health plans) attempting to access its firewall to be registered as a service center. To become a registered service center, an entity must have a fully executed Electronic Data Interchange Trading Partner Agreement on file with First Health Services and submit an Electronic Transactions Agreement to Receive X Electronic Remittance Advices for Service Centers, EDI Form-P835, for each state with which the service center desires to do business. These forms are available at Select the link to Providers and then Provider Forms and look Page 17

18 for the links to Michigan 835 Electronic Data Interchange and Michigan Electronic Transaction Agreement. Completed forms and questions on approval status should be forwarded to the First Health Services, Electronic Media Claims Coordinator by fax or at the address below. Providers with questions can call or First Health Services Media Control/Michigan EMC Processing Unit 4300 Cox Road Glen Allen, VA Upon receipt of the forms above, First Health Services will call the contact named on Form- P835 and will provide a logon ID, password, and other requirements for access to their secure FTP site. 5.4 Solving Technical Problems Pharmacies will receive one of the following messages, when the First Health Services (POS) system is down: Table 6 - Host System Problem Messages and Explanations NCPDP Message Explanation 90 Host Hung Up Host disconnected before session completed System Unavailable/Host Unavailable Planned Unavailable Processing host did not accept transaction or did not respond within time out period. Transmission occurred during scheduled downtime. Scheduled downtime for file maintenance is Sunday 11:00 p.m. - 6:00 a.m. ET. 99 Host Processing Error Do not re-transmit claims. First Health Services strongly encourages that a pharmacy s software has the capability to submit backdated claims. Occasionally, a pharmacy may also receive messages that indicate its own network is having problems communicating with First Health Services. If this occurs or if a pharmacy is experiencing technical difficulties connecting with the First Health Services system, pharmacies should follow the steps outlined below: 1. Check the terminal and communications equipment to ensure that electrical power and telephone services are operational. 2. Call the telephone number the modem is dialing and note the information heard (i.e., fast busy, steady busy, recorded message). 3. Contact the software vendor, if unable to access this information in the system. Page 18

19 4. If the pharmacy has an internal technical staff, forward the problem to that department, then internal technical staff should contact First Health Services to resolve the problem. 5. If unable to resolve the problem after following the steps outlined above, directly contact the First Health Services Technical Call Center. Refer to Appendix G: Directory at the end of this manual for contact information. Page 19

20 6.0 Online Claims Processing Edits After online claim submission is made by a pharmacy, the POS system will return a message to indicate the outcome of processing. If the claim passes all edits, a PAID message will be returned with the allowed reimbursement amount. A claim that fails an edit and is REJECTED (or DENIED) will also return with a NCPDP rejection code and message. Refer to Appendix F: POS Reject Codes & Messages for a list of POS rejection codes and messages. Page 20

21 7.0 Program Specifications 7.1 Timely Filing Limits Most pharmacies that utilize the POS system submit their claims at the time of dispensing drugs. However, there may be mitigating reasons that require a claim to be submitted retroactively. For all original claims, reversals and adjustments, the timely filing limit is 180 days from the Date Of Service (DOS). Claims that exceed the timely filing limit will deny Overrides For overrides on claims, reversals and adjustments billed past the timely filing limits of 180 days or more, pharmacies must contact the Technical Call Center. Refer to Appendix G: Directory at the end of this manual for contact information. Approved criteria for First Health Services to override the denials include: Retroactive beneficiary eligibility Third party liability (TPL) delay Retroactive disenrollment from Medicaid Health Plan Claims recovered through rebate dispute resolution as identified and agreed upon by the rebate manufacturers and the MDCH staff. First Health Services may also override claims discovered through rebate dispute resolution as identified and agreed upon by the First Health Services Rebate and the MDCH staff. 7.2 Days Supply and Maintenance Drug List Days supply information is critical to the edit functions of the ProDUR system. Submitting incorrect days supply information may cause false positive ProDUR messages or claim denial for that particular claim or for claims that are submitted in the future. Information on MDCH s dispensing policies can be found in the Pharmacy Chapter of the Michigan Medicaid Provider Manual. A maximum supply of 100 days is allowed for selected therapeutic classes. Refer to Appendix C: MDCH Maintenance Drug List for a listing of these maintenance classes. Please note that certain drugs may have specific quantity limits, which supersede this list as identified in the Michigan Pharmaceutical Product List (MPPL). Beneficiary specific prior authorization is required when requesting a maintenance quantity for other drugs. Page 21

22 7.3 Schedule II Refills According to the Michigan Board of Pharmacy, a pharmacist may partially dispense a controlled substance designated as Schedule II. If a pharmacist is unable to supply the full amount ordered in a written or emergency oral prescription, the pharmacist makes a notation of the quantity supplied on the face of the written prescription or written record of the emergency oral prescription. Except as noted below, the remainder of the prescription may be dispensed within 72 hours of the first partial dispensing. If the remainder is not or cannot be dispensed within the 72 hour period, the pharmacy must notify the prescriber and additional quantities must not be dispensed beyond the 72 hour period without a new prescription. First Health Services supports the following procedures for partial dispensing of Schedule II drugs Retail Schedule II Prescriptions The pharmacy must not charge MDCH an additional dispensing fee for filling the remainder of a partially dispensed Schedule II prescription Schedule II Prescriptions for Individuals in Long-Term Care Facilities or Beneficiaries with a Terminal Illness Prescriptions for Schedule II controlled substances that are written (1) for a beneficiary in a long-term care facility or (2) for a beneficiary with a medical diagnosis that documents a terminal illness may be filled in partial quantities, including individual dosage units. The pharmacy may not charge MDCH an additional dispensing fee for filling the remainder of a partially dispensed Schedule II prescription. The quantity dispensed in all partial fillings must not exceed the total quantity prescribed. For each partial filling, the pharmacy must record on the back of the prescription or on another appropriate record that is uniformly maintained and readily retrievable, all the following information: Date of the partial filling Quantity dispensed Remaining quantity authorized to be dispensed Identification of the dispensing pharmacist Whether the patient was terminally ill or residing in a long-term care facility Page 22

23 According to the Michigan Board of Pharmacy, Schedule II prescriptions for a patient in a long-term care facility or for a patient with a medical diagnosis that documents a terminal illness shall be valid for not more than 60 days from the issue date, unless terminated at an earlier date by the discontinuance of the medication. 7.4 Maximum Allowable Cost (MAC) Rates MDCH has MAC reimbursement levels generally applied to multi-source brand and generic products. However, MAC reimbursement may also be applied to single-source drugs or drug classifications. Refer to the MDCH Medicaid Provider Manual for additional information. The First Health Services website at provides links to new or changed MAC rates. The files on the website are provided as a convenience only to pharmacies to assist them with pre-pos adjudication decision making. The presence of a particular drug on the website MAC lists does not guarantee payment or payment level. The POS system provides up-to-date MAC information. Antihemophilic Factors - Select the link to Provider, Drug Information, and then Clotting Factor Prices. Other MACs - Select the link to Provider, Drug Information, and then MAC Price Information. This will link pharmacies to the website of MAC-Managers (the MDCH contractor for MAC administration). The MAC-Managers site requires a login with a NCPDP ID MAC Overrides A beneficiary must not be required to pay a MAC penalty (the difference between the brand name and the generic products). To receive payment above a MAC rate, prior authorization (PA) through First Health Services must be obtained. None of the DAW codes (see Table 7) alone will override a MAC rate at the point-of-sale. Page 23

24 DAW Code 0 No product selection indicated Table 7 - NCPDP Dispense As Written (DAW) Code Values 1 Substitution not allowed by prescriber Explanation 2 Substitution allowed - patient requested product dispensed 3 Substitution allowed - pharmacist selected product dispensed 4 Substitution allowed - generic product not in stock 5 Substitution allowed - brand drug dispensed as a generic 6 Override 7 Substitution not allowed - brand mandated by law 8 Substitution allowed - generic drug unavailable in the marketplace 9 Other Pharmacies should note the following First Health Services claims processing logic that applies when a MAC exists and: If DAW 1 is submitted and PA is on file for the beneficiary; the claim will reimburse at the brand name rate instead of the MAC. If DAW 1 is not submitted and PA is on file for a beneficiary, the claim will pay with logic that includes MAC price. The MAC will not be overridden. If DAW 2 is submitted, the claim will deny unless PA is on file for the beneficiary. DAW 2 (the patient requested the product) will not substantiate PA for a MAC override. Page 24

25 7.5 Prior Authorization (PA) The PA process is designed to provide rapid and timely responses to requests. PAs are managed by three ways: pharmacy level overrides, the Clinical Call Center, and the Technical Call Center. Call centers are described under Section First Health Services Call Centers in this manual and contact information is listed in Appendix G: Directory at the end of this manual. Table 8 lists examples of various prior authorization procedures. The First Health Services call centers are responsible for reviewing requests. The health care provider is responsible for obtaining prior authorization. Table 8 - Prior Authorization (PA) Procedures Examples of PA Products or Edit Types Where to Call Who Should Call Drugs Not Listed on the Michigan Pharmaceutical Product List Drugs Listed on the Michigan Pharmaceutical Product List (MPPL) as Requiring PA MAC Price Overrides MACs are set on multiple source drugs & some therapeutic classes. Payment for product cost will not exceed a drug s MAC price regardless of the brand dispensed unless PA is granted. Clinical Call Center Clinical Call Center Prescribers Prescribers Quantity Limitations Clinical Call Center Pharmacies or Prescribers Cost Sharing Payments for Medicare Part B Covered Drugs Rounding Edit First Health Services codes for certain drugs to only allow whole multiples of the package size Early Refills for Ambulatory Beneficiaries Each claim submitted is evaluated to determine if at least 75% of the previous fill of the same drug product has been used. Claims will deny at the POS if the utilization requirement has not been met. Clinical Call Center Clinical Call Center Technical Call Center Pharmacies Pharmacies Pharmacies Page 25

26 Examples of PA Products or Edit Types Where to Call Who Should Call Early Refills for LTC Beneficiaries An exception is allowed, when the Early Refill edit is hitting because of a LTC new admission or a re-admission and the beneficiary s Level of Care (LOC) code is 02, 16, 55, or 56. Pharmacy Level Override Pharmacies may override PA by entering a Submission Clarification Code = 05. If the beneficiary is not flagged as an active LTC beneficiary, the claim will deny. 7.6 Special Eligibility Situations Newborns The newborn s Medicaid ID number must be transmitted on the pharmacy claim. If the newborn s Medicaid ID number is not available, contact the MDCH Enrollment Services Section. Refer to the Directory Appendix in the Michigan Medicaid Provider Manual Lock-In Beneficiaries For information regarding lock-in beneficiaries refer to the Beneficiary Eligibility Chapter in the Michigan Medicaid Provider Manual Retroactive Eligibility Pharmacies may bill for prescriptions dispensed to beneficiaries who become retroactively eligible for Medicaid. Pharmacies must contact the Technical Call Center to obtain approval for retroactive prior authorization or timely filing overrides in cases when eligibility was retroactive. 7.7 Managed Care Plans and Pharmacy Carve-Out Lists MDCH contracts with capitated managed care plans to provide services for its beneficiaries. These plans are responsible for most pharmacy services. Carve-out exceptions are explained in the next sections. The plans develop their own preferred drug lists, prior authorization requirements, reimbursement formulas, and utilization controls that differ from MDCH fee-forservice programs. Additional information on managed care is available in the Medicaid Health Plans and Adult Benefits Waiver (ABW) Chapters of the Michigan Medicaid Provider Manual. Page 26

27 7.7.1 Pharmacy Carve-Outs Selected drugs and classes are carved out from the managed care plan coverage and are paid directly to a pharmacy by the MDCH fee-for service program. For these drugs, pharmacies must bill First Health Services for reimbursement. The First Health Service website at includes separate carve-out lists for Medicaid Health Plans and for ABW County Health Plans. Select the link to Providers and then Drug Information to view each list Michigan Medicaid Health Plan Carve-Outs Pharmacies will not be reimbursed for prescriptions dispensed to beneficiaries enrolled in the Medicaid Health Plans except for drugs designated as 100% carve-out. Medicaid Health Plans may also receive 60% of the MDCH-allowable reimbursement for selected drugs and classes. If a pharmacy bills First Health Services for drug products designated in this category, the claim will be denied with a transaction message to bill the Medicaid Health Plan Adult Benefits Waiver (ABW) County Health Plan Carve-Out Pharmacies will not be reimbursed for prescriptions dispensed to beneficiaries enrolled in the ABW County Health Plans except for drugs designated as 100% carve-out. 7.8 Compound Claims MDCH reimbursement includes a compound dispensing fee. Refer to the Pharmacy Chapter of the Michigan Medicaid Provider Manual for information and reimbursement rates. To request the compounded dispensing fee from the POS system, pharmacies must: Enter 1 in the Transaction Count (NCPDP #109-A9). For compounds, only one transaction is allowed for transmission. Enter 2 in the Compound Code (NCPDP #406-D6) to indicate the drug dispensed is a compound. Enter the Product Service ID/NDC (NCPDP #407-D7) for the most expensive legend ingredient. Enter the Ingredient Cost (NCPDP #409-D9) for the entire compound. Page 27

28 7.8.1 Exceptions Requiring Universal Claim Form (UCF) Submission When (1) the lower of Usual & Customary or Gross Amount Due exceeds $250 or (2) a pharmacy is requesting a dispensing fee for compound capsules or suppositories, payment requires submission of a paper claim. Completion instructions for the Universal Claim Form are provided at Appendix B: Universal Claim Form, Version 5.1 of this manual. 7.9 Home Infusion Therapy Claims MDCH reimburses an additional single all-inclusive fee, above the standard dispensing fee for the diluent and vehicle that is administered with the active ingredient. Refer to the Pharmacy chapter of the Michigan Medicaid Provider Manual for additional information and the reimbursement rate. To request the dispensing fee for home infusion therapy, pharmacies must: Submit each ingredient of the home infusion therapy individually. Enter 8 in the 12-digit Prior Authorization Type Code (NCPDP #461-EU) of the Claim Segment Unit Dose Claims MDCH reimbursement includes a unit dose incentive fee for long-term care pharmacies that have approved unit dose agreements. The incentive fee is based on a per unit rate for pharmacy re-packaged unit dose and is applicable to capsules or tablets only. Refer to the Pharmacy chapter of the MDCH Medicaid Provider Manual for additional information. To apply to become approved for the unit dose incentive fee, long-term care pharmacies must submit a completed Unit Dose Pharmacy Agreement to First Health Services. This form and mailing instructions are available on the First Health Services website at Select the link to Providers and then Provider Forms. Completed forms should be sent to the First Health Services Provider Relation Department. Refer to Appendix G: Directory at the end of this manual. To bill for the unit dose incentive fee, approved long-term care pharmacies must: Page 28 Enter the unit dose incentive fee in the Incentive Amount Submitted (NCPDP #438-E3) of the Pricing Segment. Enter a value of 3 in the Unit Dose Indicator (NCPDP #429-DT) of the Claims Segment, to represent that the product was repackaged as unit dose. Without this entry the Incentive Amount Submitted charge will not be used in a pharmacy s payment.

29 The incentive is paid only to an approved long-term care pharmacy Medical Supplies and Pre-Filled Syringes Effective for dates of service January 1, 2006, and after, MDCH no longer covers the following medical supply items and pre-filled syringes as a pharmacy benefit. These items are covered only as a medical supplier benefit billed using the appropriate procedures on the ANSI X12N 837P, version 4010A1, or CMS 1500 format not on the NCPDP version 5.1, Batch 1.1, or Universal Claim format. Blood glucose test strips Lancets Urine glucose/acetone test strips Nutritional supplements (e.g., protein replacements and infant formulas) Heparin lock flush pre-filled syringes Normal saline pre-filled syringes Pharmacies desiring to become approved MDCH medical suppliers must refer to the General Information for Providers chapter of the Michigan Medicaid Provider Manual. First Health Services is not responsible for medical supplier enrollment. Page 29

30 8.0 Coordination of Benefits (COB) Coordination of Benefits (COB) is the mechanism used to designate the order in which multiple carriers are responsible for benefit payments and, thus, prevention of duplicate payments. Third Party Liability (TPL) refers to: An insurance plan or carrier Program Commercial carrier The plan or carrier can be: An individual Group Employer-related Self-insured Self-funded plan The program can be Medicare which has liability for all or part of a beneficiary s medical or pharmacy coverage. The commercial carrier can be automobile insurance and workers compensation. The terms third party liability and other insurance are used interchangeably to mean any source other than Medicaid that has a financial obligation for health care coverage. Pharmacies should refer to the Coordination of Benefits Chapter of the MDCH Medicaid Provider Manual for specific requirements. MDCH is always the payer of last resort. For beneficiaries who have other insurance coverage, pharmacies must bill the other insurance carriers (including Medicare) before billing MDCH. Further, pharmacies must investigate and report the existence of other insurance or liability and must utilize the other payment sources to their fullest extent prior to filing a claim with MDCH. Page 30

31 8.1 COB General Instructions Identifying Other Insurance Coverage From MDCH Sources Other insurance information is not displayed on the beneficiary s mihealth card. Pharmacies are responsible for verifying eligibility and other insurance information using the MDCH Eligibility Verification System (EVS). Refer to Directory Appendix in the Michigan Medicaid Provider Manual for contact information on MDCH EVS POS Claims If a beneficiary has other coverage on a date of service and it is not reported on the pharmacy s claim submission, First Health Services will deny the claim in the POS system and return the following information in the Additional Message field. Carrier ID (Refer to the next section for a description) Carrier Name Beneficiary Policy Number Carrier ID List A master Carrier ID List, providing carrier codes, names, and addresses, is available on the MDCH website. The First Health Services website at provides a quick link to this file. Select the link to Links and then Michigan Department of Community Health s Carrier ID Listing. The 8-digit MDCH Carrier ID must be reported in the Other Payer ID field of NCPDP specifications. If a beneficiary has other insurance and that carrier is not identified on the MDCH Carrier ID Listing, pharmacies may enter in the Other Payer ID Other Insurance Discrepancies on MDCH Files If the beneficiary does not agree with the other insurance information contained in the MDCH EVS or provided by First Health Services (e.g., other insurance coverage no longer exists), the beneficiary should be instructed to notify the MDCH Beneficiary Help Line available at Pharmacies have three methods for reporting other insurance information to the MDCH Revenue and Reimbursement Division: to [email protected]. Page 31

32 Phone the MDCH Provider Hotline at and select option 4 to route your call to the Revenue and Reimbursement Division. Fax your request and supportive documentation to The MDCH Revenue and Reimbursement Third Party Liability (TPL) staff validates the accuracy of other insurance changes prior to updating the MDCH system files. This validation sometimes requires additional followup with insurance carriers. Resolution normally takes 24 to 48 hours. MDCH TPL staff is only available Monday through Friday 8:00 a.m. to 4:30 p.m. Changes are transmitted to First Health Services weekly on Sunday night. For life-threatening emergencies, it is possible to update the First Health Services system within 24 hours (excluding weekends). Page 32

33 8.1.2 Third Party Liability (TPL) Processing Grid Pharmacies must comply with the instructions in the Third Party Liability Processing Grid for appropriate Other Coverage Code values to report in the Claim Segment. The TPL Processing Grid is available at Select the link to Providers, Other Notices, and then Pharmacy Claims Submission. The following table (Table 9) summarizes values for the Other Coverage Code. Table 9 - Other Coverage Code Code Descriptions Comments 1 No Other Coverage If other insurance is indicated on the MDCH eligibility file, First Health Services will process the claim as TPL regardless of what Other Coverage Code is submitted. 2 Other Coverage Exists - Payment Collected 3 Other Coverage Exists - This Claim Not Covered 4 Other Coverage Exits - Payment Not Collected 5 Managed Care Plan Denial 6 Other Coverage Denied - Not A Participating Provider 7 Other Coverage Exists - Not In Effect On DOS 8 Claim is billing for co-payment. When this value is used, the pharmacy must report the other insurance payment collected and bill MDCH only for the beneficiary s liability. Payment will not exceed MDCH allowed amounts. This value will pay when a drug is not covered by the beneficiary s other insurance, but is covered by MDCH and a valid Other Payer Reject Code (NCPDP #472-6E) is submitted. Claims not meeting this requirement will be denied with NCPDP Reject Code 6E, Missing/Invalid Other Payer Code. This value must be used only when a beneficiary has not met the other insurer s deductible or the drug cost is less than the beneficiary s other insurer s co-pay. Payment will not exceed MDCH allowed amounts. No longer supported. These values will result in payment denial of with NCPDP Reject Code 13, Missing/Invalid Other Coverage Code, which cannot be overridden. Page 33

34 8.1.3 First Health Services COB Processing If a beneficiary has other coverage on the date of service and other payments amounts were not listed on the claim, First Health Services will deny payment with: NCPDP Error Code 41, Submit Bill to Other Processor or Primary Payer, and The following information in the Additional Message field: Carrier ID (the MDCH unique 8-digit code identifying the other insurer) Carrier Name Beneficiary Policy Number If other insurance is indicated on the MDCH eligibility file, First Health Services will process the claim as TPL, regardless of what TPL codes the pharmacy submits. Also, if no other insurance is indicated on the MDCH eligibility file but the pharmacy submits TPL data, First Health Services will process the claim using the other payment amounts. If payment is received from multiple other carriers, First Health Services requires pharmacies enter the amount paid from all valid carriers in the repeating Other Payer fields The MDCH Pharmaceutical Product List (MPPL) & COB Before MDCH payment will be made for claims with other insurance liabilities, all requirements listed in the MPPL must be met. This includes prior authorization requirements. Page 34

35 8.2 Special Instructions for Medicare Part B and Part D Pharmacies must bill Medicare prior to billing MDCH for a beneficiary s prescription costs. Part B is medical insurance for doctor services, outpatient hospital care, durable medical equipment, and some take-home drugs. Part D is the Medicare prescription drug program that was implemented January 1, As explained in the next sections, there are unique COB considerations for Medicare Parts B and D Identifying Individuals Enrolled in Medicare MDCH uses its own 8-digit Carrier IDs (Table 10) to identify beneficiaries eligible or enrolled in Medicare. Table 10 - MDCH Carrier IDs Identifying Medicare Other Payer Carrier ID Description Comments Medicare - Eligible for, but not enrolled Applies to both Part B & D Medicare - Eligible for, but not confirmed by CMS Applies to both Part B & D Medicare - Eligible in Part A Medicare - Eligible, but not enrolled in Medicare Part D Medicare - Enrolled in Medicare Part D Medicare - Enrolled in Part B Medicare - Enrolled in Medicare Advantage Plan Medicare - Aliens, but not enrolled If the beneficiary is less than 65 years old and after confirming the beneficiary is not Medicare eligible, the pharmacy may call the First Health Services Technical Call Center for an override. Page 35

36 8.2.2 Medicare Part B Appendix D: Medicare Part B Covered Drugs of this manual lists examples of drugs commonly covered by Medicare Part B. For these and other drugs covered by Medicare Part B, pharmacies must first bill Medicare prior to billing MDCH. After the payment is received from Medicare Part B, MDCH may pay the co-pays/coinsurance/deductible up to the MDCH allowable reimbursement levels and if pharmacies: Obtain override from the First Health Services Clinical Call Center for payment of the Part B coinsurance. If claims are denied payment by Medicare, the pharmacy must submit appropriate documentation (e.g., Explanation of Benefits or Remittance Advices) from Medicare prior to being granted an override for payment by the Clinical Call Center. Bill with Other Coverage Code 2 in the Claim Segment, after obtaining the Clinical Call Center s authorization. When pharmacies do not reflect Medicare Part B payments, their billings will deny with: NCPDP Error Code 41, Submit claim to other processor or primary payer, and An Additional Message, Bill Medicare Part B Medicare Part D Effective for dates of service on January 1, 2006, and after, beneficiaries dually eligible/enrolled in Medicare and Medicaid (the dual eligibles) receive most prescription drug coverage from Part D. Further, MDCH will not reimburse Part D prescription drug co-pays, coinsurance or deductibles for beneficiaries who are eligible for or enrolled in Part D. For additional information about Medicare Part D plans, pharmacies may visit the Center for Medicare and Medicaid Services (CMS) website at or call MEDICARE or call which is the CMS dedicated pharmacy help line. For dual eligibles, MDCH continues to pay (1) for Part B co-pays/deductibles/coinsurance (as previously described) and (2) for the following Part D excluded drug classes as stipulated in the Michigan Pharmaceutical Product List (MPPL): Benzodiazepines Barbiturates Specific Over-The-Counter (OTC) drugs Specific Prescription Vitamins/Minerals Smoking Cessation Products Page 36

37 All MDCH coverage edits and utilization controls remain in place for the Part B copays/coinsurance/deductibles payments and for the Part D excluded drug classes. Other claims submitted for dual eligibles will deny with the following information. NCPDP Error Code 41, Submit Bill to Other Processor or Primary Payer. For the dual eligibles, NCPDP Error Code 41 cannot be overridden. Coordination of Benefits (COB) overrides is not allowed for Part D covered drugs. Part D plan information in the Additional Message field: Medicare Contract/Plan ID Plan Name Plan Phone Number Page 37

38 Appendix A: Payer Specifications for NCPDP 5.1 B1 (Billing) and B3 (Re-Bill) Transactions Requirement Key: M = Mandatory R = Required O = Optional NS = Not Supported ***R = Repeating Transaction Header Segment Name Requirement Segment MANDATORY for all transactions Values Supported for MDCH Programs 1Ø1-A1 Bin Number M ØØ9737 (MICHIGAN Medicaid) 1Ø2-A2 Version/Release Number M 51 1Ø3-A3 Transaction Code M B1 (or B3 for re-bill) 1Ø4-A4 Processor Control Number M PØØ8ØØ9737 (MICHIGAN Medicaid) 1Ø9-A9 Transaction Count M 2Ø2-B2 Service Provider ID Qualifier M B1 or B3 = 1-4 Except for multi-ingredient compounds, when only one transaction is allowed per transmission, the entry must 1. Ø7 = NCPDP (NABP) Provider ID 2Ø1-B1 Service Provider ID M NCPDP (NABP) Provider Number [Pharmacy Specific] 4Ø1-D1 Date of Service M Format = CCYYMMDD 11Ø-AK Software Vendor/Certification ID M Assigned when vendor is certified with First Health Services. Billings will reject if this number is missing or not valid. Page 38

39 Patient Segment Name Requirement Segment REQUIRED for B1 & B3 111-AM Segment Identification M Ø1 = Patient Segment 331-CX Patient ID Qualifier O 332-CY Patient ID O Values Supported for MDCH Programs 3Ø4-C4 Date of Birth R Required for this program. 3Ø5-C5 Patient Gender Code R Required for this program. 31Ø-CA Patient First Name R Required for eligibility validation. 311-CB Patient Last Name R Required for eligibility validation. 322-CM Patient Street Address O 323-CN Patient State/Providence Address 324-CO Patient Zip/Postal Zone O 326-CQ Patient Phone Number O 3Ø7-C7 Patient Location S Not required for this program. 333-CZ Employer ID O 334-1C Smoker/Non-Smoker Code O 335-2C Pregnancy Indicator O O Insurance Segment Name Requirement Segment MANDATORY for B1 & B3 Values Supported for MDCH Programs 111-AM Segment Identification M Ø4 = Insurance Segment 3Ø2-C2 Cardholder ID M 10-digit ID Number (2 zeros in front of the 8-digit MDCH Beneficiary ID) 312-CC Cardholder First Name O 313-CD Cardholder Last Name O 314-CE Home Plan O 524-FO Plan ID O 3Ø9-C9 Eligibility Clarification Code 336-8C Facility ID O O Page 39

40 Insurance Segment Name Requirement Segment MANDATORY for B1 & B3 3Ø1-C1 Group ID R MIMEDICAID 3Ø3-C3 Person Code O 3Ø6-C6 Patient Relationship Code O 1 = Cardholder Values Supported for MDCH Programs Claim Segment Name Requirement Segment MANDATORY for B1 & B3 111-AM Segment Identification M Ø7 = Claim Segment 455-EM 4Ø2-D2 Prescription/Service Reference Number Qualifier Prescription/Service Reference Number 436-E1 Product/Service ID Qualifier Values Supported for MDCH Programs M 1 = Rx Billing 4Ø7-D7 Product/Service ID M NDC 456-EN 457-EP 458-SE Associated Prescription/Service Reference # Associated Prescription/Service Date Procedure Modifier Code Count M M NS NS 459-ER Procedure Modifier Code O***R*** O Ø3 = NDC MDCH does not accept partial fill claims at this time. MDCH does not accept partial fill claims at this time. 442-E7 Quantity Dispensed R Required for this program. Entry must be metric decimal in a 9(7) v999 format. 4Ø3-D3 Fill Number R Required for this program. Ø = Original with 1 through 99 for refill number. 4Ø5-D5 Days Supply R Required for this program. 4Ø6-D6 Compound Code S Ø= Not specified 1 = Not a compound 2 = Compound 4Ø8-D8 Dispense As Written R Ø = No product selection indicated Page 40

41 Claim Segment Segment MANDATORY for B1 & B3 Name Requirement Values Supported for MDCH Programs (DAW)/Product Selection Code MAC overrides are allowed only with prior authorization and not with DAW codes alone at point-of-sale. 1 = Substitution not allowed by prescriber 2 = Substitution allowed - patient requested brand 3 = Substitution allowed - pharmacist selected product dispensed 4 = Substitution allowed - generic drug not in stock 5 = Substitution allowed - brand drug dispensed as generic 6 = Override 7 = Substitution not allowed - brand drug mandated by law 8 = Substitution allowed - generic drug not available in marketplace 9 = Other 414-DE Date Prescription Written R Required for this program. 415-DF Number of Refills Authorized R Required for this program. 419-DJ Prescription Origin Code O 42Ø-DK Submission Clarification Code S Required when clarification is needed in these provider-level override conditions (SCC=5/LTC situations). Refer to the Pharmacy Claims Processing Manual for additional details. 3Ø8-C8 Other Coverage Code S Required for coordination of benefits processing. ØØ = Not specified Ø1 = No other coverage Ø2 = Other coverage exists - payment collected Ø3 = Other coverage exists - claim not covered Page 41

42 Claim Segment Name Requirement 429-DT Unit Dose Indicator S 453-EJ 445-EA 446-EB Originally Prescribed Product/Service ID Qualifier Originally Prescribed Product/Service Code Originally Prescribed Quantity 33Ø-CW Alternate ID O 454-EK Scheduled Prescription ID Number 6ØØ-28 Unit of Measure O 418-DI Level of Service O 461-EU 462-EV 463-EW 64-EX Prior Authorization Type Code Prior Authorization Number Submitted Intermediary Authorization Type ID Intermediary Authorization ID O O O O S O O O Segment MANDATORY for B1 & B3 Values Supported for MDCH Programs Ø4 = Other coverage exists - payment not collected Values 05, 06, 07, and 08 are no longer allowed for MDCH programs. Required when the pharmacy has repackaged a non-unit dose product. 3 = Pharmacy Re-Package Unit Dose Required when needed to identify designated prior authorization and/or override conditions (Home Infusion Therapy Dispense Fee). Refer to the Pharmacy Claims Processing Manual for additional details. 343-HD Dispensing Status NS MDCH does not accept partial fill claims at this time. Page 42

43 344-HF 345-HG Claim Segment Name Quantity Intended to be Dispensed Days Supply Intended to be Dispensed Requirement NS NS Segment MANDATORY for B1 & B3 Values Supported for MDCH Programs MDCH does not accept partial fill claims at this time. MDCH does not accept partial fill claims at this time. Pharmacy Provider Segment Segment NOT REQUIRED at this time. s intentionally not listed. Possible future use. Prescriber Segment Segment REQUIRED for these transactions: B1 and B3. Name Requirement Values Supported for MDCH Programs 111-AM Segment Identification M Ø3 = Prescriber Segment 466-EZ Prescriber ID Qualifier R 12 = DEA 411-DB Prescriber ID R DEA Number of the prescriber. If the prescriber does not have a DEA number, use ZZ ZZ is not allowed for scheduled controlled substances E Prescriber Location Code O 427-DR Prescriber Last Name O 498-PM Prescriber Phone Number O 468-2E Primary Care Provider ID Qualifier 421-DL Primary Care Provider ID O 469-H5 Primary Care Provider Location Code 47Ø-4E Primary Care Provider Last Name O O O Page 43

44 COB Segment Name Segment REQUIRED for transactions B1and B3, if there is OTHER PAYER information. Requirement Values Supported for MDCH Programs 111-AM Segment Identification M Ø5 = Coordination of Benefits/Other Payments Segment 337-4C Coordination of Benefits/Other Payments Count 338-5C Other Payer Coverage Type 339-6C Other Payer ID Qualifier M Max = 3 M***R*** Max = 3 S***R*** Max = 3 Ø1 = Primary Ø2 = Secondary Ø3 = Tertiary Required for this program to qualify the Other Payer ID. 99 = Other 34Ø-7C Other Payer ID S***R*** Use with Coordination of Benefits. 443-E8 Other Payer Date 341-HB 342-HC 431-DV Other Payer Amount Paid Count Other Payer Amount Paid Qualifier Other Payer Amount Paid Max = 3 Other Payer ID = MDCH Carrier ID (8- digits) S***R*** Max = 3 S S***R*** Max = 3 S***R*** Max = 3 Use with Coordination of Benefits. Use with Coordination of Benefits. Use with Coordination of Benefits. Ø8 = Sum of all reimbursement Use with Coordination of Benefits E Other Payer Reject Count S***R*** Use with Other Coverage Code (3Ø8-C8) = 1 or E Other Payer Reject Code S***R*** Use with Other Coverage Code (3Ø8-C8) = 1 or 3. Workers' Compensation Segment Segment NOT REQUIRED. s intentionally not listed. Possible future use. Page 44

45 DUR/PPS Segment Name Segment REQUIRED for transactions B1 and B3, if there is DUR information. Requirement Values Supported for MDCH Programs 111-AM Segment Identification M Ø8 = DUR/PPS Segment 473-7E DUR/PPS Code Counter 439-E4 Reason for Service Code 44Ø-E5 Professional Service Code 441-E6 Result of Service Code S***R Max = 9 S***R Max = 9 S***R Max = 9 S***R Max = E DUR/PPS Level of Effort O***R*** 475-J9 DUR Co-Agent ID Qualifier O***R*** 476-H6 DUR Co-Agent ID O***R*** Required when needed to communicate DUR information. Required when needed to communicate DUR information. Refer to Section E.3 - DUR Reason for Service in this manual. Required when needed to communicate DUR information. Refer to Section E.4 - DUR Professional Service in this manual. Required when needed to communicate DUR information. Refer to Section E.5 - DUR Result of Service in this manual. Pricing Segment Name Requirement Segment MANDATORY for B1 & B3 111-AM Segment Identification M 11 = Pricing Segment 4Ø9-D9 Ingredient Cost Submitted R 412-DC Dispensing Fee Submitted O 477-BE Professional Fee Submitted O 433-DX Patient Paid Amount Submitted 438-E3 Incentive Amount Submitted 478-H7 Other Amount Claimed Submitted Count O S O Values Supported for MDCH Programs Required when billing for pharmacy repackaged unit dose on tablets and capsules only. Page 45

46 Pricing Segment Name 479-H8 Other Amount Claimed Submitted Qualifier 48Ø-H9 481-HA 482-GE 483-HE 484-JE 426-DQ Other Amount Claimed Submitted Flat Sales Tax Amount Submitted Percentage Sales Tax Amount Submitted Percentage Sales Tax Rate Submitted Percentage Sales Tax Basis Submitted Usual And Customary Charge Requirement 43Ø-DU Gross Amount Due R 423-DN Basis Of Cost Determination O O O O O O R O Segment MANDATORY for B1 & B3 Values Supported for MDCH Programs Coupon Segment Segment NOT REQUIRED at this time; fields intentionally not listed. Possible future use. 111-AM 45Ø-EF Page 46 Compound Segment Name Segment Identification Compound Dosage Form Description Code Segment NOT required, but MIC will be implemented at an undetermined future date. Specifications will be provided later. Requirement NS Values Supported for MDCH Programs Currently not used; implementation planned in the future. Blank = Not Specified Ø1 = Capsule Ø2 = Ointment Ø3 = Cream

47 451-EG Compound Segment Name Compound Dispensing Unit Form Indicator Segment NOT required, but MIC will be implemented at an undetermined future date. Specifications will be provided later. Requirement NS Values Supported for MDCH Programs Ø4 = Suppository Ø5 = Powder Ø6 = Emulsion Ø7 = Liquid 1Ø = Tablet 11 = Solution 12 = Suspension 13 = Lotion 14 = Shampoo 15 = Elixir 16 = Syrup 17 = Lozenge 18 = Enema Currently not used; implementation planned in the future. Blank = Not Specified Ø1 = Capsule Ø2 = Ointment Ø3 = Cream Ø4 = Suppository Ø5 = Powder Ø6 = Emulsion Ø7 = Liquid 1Ø = Tablet 11 = Solution 12 = Suspension 13 = Lotion 14 = Shampoo 15 = Elixir 16 = Syrup Page 47

48 452-EH Compound Segment Name Compound Route of Administration Segment NOT required, but MIC will be implemented at an undetermined future date. Specifications will be provided later. Requirement NS Values Supported for MDCH Programs 17 = Lozenge 18 = Enema Currently not used; implementation planned in the future. Ø = Not Specified 1 = Buccal 2 = Dental 3 = Inhalation 4 = Injection 5 = Intraperitoneal 6 = Irrigation 7 = Mouth/Throat 8 = Mucous Membrane 9 = Nasal 1Ø = Ophthalmic 11 = Oral 12 = Other/Miscellaneous 13 = Otic 14 = Perfusion 15 = Rectal 16 = Subligual 17 = Topical 18 = Transdermal 19 = Translingual 2Ø = Urethral 21 = Vaginal 22 = Enteral 447-EC Compound Ingredient Component Count NS Currently not used; implementation planned in the future. There is a maximum of 25 iterations. Page 48

49 488-RE Compound Segment Name Compound Product ID Qualifier Segment NOT required, but MIC will be implemented at an undetermined future date. Specifications will be provided later. Requirement NS Values Supported for MDCH Programs Currently not used; implementation planned in the future. 489-TE Compound Product ID NS***R*** Currently not used; implementation planned in the future. There is a maximum of 25 iterations. 448-ED 449-EE 49Ø-UE Compound Ingredient Quantity Compound Ingredient Drug Cost Compound Ingredient Basis of Cost Determination NS NS NS Currently not used; implementation planned in the future. Currently not used; implementation planned in the future. Currently not used; implementation planned in the future. Prior Authorization Segment Segment NOT REQUIRED at this time; fields intentionally not listed. Future use. Clinical Segment Segment REQUIRED for transactions B1 & B3, if designated clinical information is needed for coverage consideration. Name Requirement Values Supported for MDCH Programs 111-AM Segment Identification M 13 = Clinical Segment 491-VE 492-WE 424-DO 493-XE Diagnosis Code Count Diagnosis Code Qualifier Diagnosis Code Clinical Information Counter O Max = 5 O***R*** Max = 5 O***R*** Max = ZE Measurement Date O 495-H1 Measurement Time O 496-H2 Measurement Dimension O O Page 49

50 Clinical Segment Segment REQUIRED for transactions B1 & B3, if designated clinical information is needed for coverage consideration. Name Requirement Values Supported for MDCH Programs 497-H3 Measurement Unit O 498-H4 Measurement Value O Transaction Trailer Trailer Mandatory for all files. Name Requirement Values Supported for MDCH Programs 88Ø-K4 Text Indicator M Start of Text 7Ø1 Segment Identifier M 99 = File Trailer Record 8Ø6-5C Batch Number M Assigned by Sender. Must Match Header Record. 751 Record Count M Include The Header and Trailer in the Count 5Ø4-F4 Message M Leave Spaces Blank 88Ø-K4 Text Indicator M End of Text Page 50

51 B2 Transaction - Reversals Requirement Key: M = Mandatory R = Required O = Optional NS = Not Supported ***R = Repeating Transaction Header Segment Segment MANDATORY for all transactions. Name Requirement Values Supported for MDCH Programs 1Ø1-A1 Bin Number M (ØØ9737) MICHIGAN Medicaid 1Ø2-A2 Version/Release Number M 51 1Ø3-A3 Transaction Code M B2 1Ø4-A4 Processor Control Number M (PØØ8ØØ9737) MICHIGAN Medicaid 1Ø9-A9 Transaction Count M 2Ø2-B2 Service Provider ID Qualifier M B2 = 1-4 (Except multi-ingredient compound = 1) Ø7 = NCPDP (NABP) Provider ID 2Ø1-B1 Service Provider ID M NCPDP (NABP) Provider Number or Plan Specific <provider specific> 4Ø1-D1 Date of Service M The format is CCYYMMDD. 11Ø-AK Software Vendor/Certification ID M Assigned when software vendor is certified with FIRST HEALTH SERVICES; will reject if missing or not valid. Claim Segment Name Requirement Segment MANDATORY for B2 111-AM Segment Identification M Ø7 = Claim Segment 455-EM 4Ø2-D2 Prescription/Service Reference Number Qualifier Prescription/Service Reference Number M M Values Supported for MDCH Programs 1 = Rx billing 436-E1 Product/Service ID Qualifier O Ø3 = NDC 4Ø7-D7 Product/Service ID O NDC 442-E7 Quantity Dispensed O Page 51

52 Claim Segment Name Requirement 4Ø3-D3 Fill Number O 4Ø5-D5 Days Supply O 4Ø6-D6 Compound Code O 4Ø8-D8 Dispense As Written (DAW)/Product Selection Code 414-DE Date Prescription Written O 415-DF 42Ø-DK Number of Refills Authorized Submission Clarification Code 3Ø8-C8 Other Coverage Code O 429-DT Unit Dose Indicator O 418-DI Level of Service O 461-EU Prior Authorization Type Code O O O O Segment MANDATORY for B2 Values Supported for MDCH Programs DUR/PPS Segment Name Segment REQUIRED for these transactions: B2 if there is DUR information. Requirement Values Supported for MDCH Programs 111-AM Segment Identification M Ø8 = DUR/PPS Segment 473-7E DUR/PPS Code Counter 439-E4 Reason For Service Code 44Ø-E5 Professional Service Code 441-E6 Result of Service Code O***R Max = 9 O***R Max = 9 O***R Max = 9 O***R Max = 9 Page 52

53 Pricing Segment Name Requirement Segment SITUATIONAL for B2 Values Supported for MDCH Programs 111-AM Segment Identification M 11 = Pricing Segment 4Ø9-D9 Ingredient Cost Submitted O 412-DC Dispensing Fee Submitted O 433-DX Patient Paid Amount Submitted O 438-E3 Incentive Amount Submitted O 426-DQ Usual And Customary Charge O 43Ø-DU Gross Amount Due O Transaction Trailer Name Requirement Trailer Mandatory for all files. 88Ø-K4 Text Indicator M Start of Text Values Supported for MDCH Programs 7Ø1 Segment Identifier M 99 = File Trailer Record 8Ø6-5C Batch Number M Assigned By Sender. Must Match Header Record. 751 Record Count M Include The Header And Trailer In The Count 5Ø4-F4 Message M Leave Spaces Blank 88Ø-K4 Text Indicator M End of Text Page 53

54 Appendix B: Universal Claim Form, Version 5.1 All paper pharmacy claims must be submitted to First Health Services on a Universal Claim Form (UCF) which may be obtained from a pharmacy s wholesaler. The Appendix G: Directory at the end of this manual specifies (1) an alternative source for universal claim forms and (2) the First Health Services address that pharmacies should mail UCF billings. Page 54

55 Completion Instructions for the Universal Claim Form: 1. Complete all applicable areas on the front of the form. Type or print the information legibly. The use of correction fluid is not acceptable. Each area is numbered. 2. Verify patient information is correct and that patient named is eligible for benefits. 3. Ensure that the patient s signature is in the authorization box in the certification section on front side of the form for prescription(s) dispensed. 4. Do not exceed 1 set of DUR/PPS codes per claim. 5. Worker s Compensation Injury Claims - Enter Workers Compensation in the Product Service ID area and complete the Workers Comp. Information on the front side of the form. 6. Compound Prescriptions - Enter Compound Rx in the Product / Service I.D. area and list each ingredient name, NDC, quantity, and cost in the Product / Service I.D. box. Use a new Universal Claim Form for each compound prescription. 7. Home Infusion Therapy - Enter Home IV in the Product / Service I.D. area and enter 8 for the Prior Authorization Type Code. A standard claim for each ingredient with New Rx number for each ingredient. Definition of Values In addition to the general guidelines above, pharmacies must use the code values listed when completing the following selected fields of the Universal Claim Form. 1. Other Coverage Code 0 Not specified 1 No other coverage identified 2 Other coverage exists - payment collected 3 Other coverage exists - this claim not covered 4 Other coverage exists - payment not collected 5-8 Not supported 2. Person Code Code assigned to a specific person within a family. 3. Patient Gender Code 0 Not specified 1 Male 2 Female Page 55

56 4. Patient Relationship Code 1 Cardholder 5. Service Provider ID Qualifier 07 NCPDP Provider ID 6. Carrier ID in Workers Comp. Information Leave blank, unless workers compensation applies. Enter the Carrier Code assigned in Workers Compensation Program. 7. Claim/Reference ID Enter the claim number assigned by Worker s Compensation Program. 8. Prescription Service Reference # Qualifier Blank Not specified 1 Rx billing 2 Service billing 9. Quantity Dispensed Enter Quantity dispensed expressed in metric decimal units (shaded areas for decimal values). 10. Product/Service ID Qualifier (Qual) This is the code qualifying the value in Product/Service ID (NCPDP #407-07). If compound is used, enter the most expensive NDC ingredient. 03 National Drug Code (NDC) 11. Prior Authorization Type Code (PA Type) 0 Not specified 1 Prior Authorization 2 Medical Certification 3 EPSDT (Early Periodic Screening Diagnosis Treatment) 4 Exemption from co-pay 5 Exemption form Rx limits 6 Family Planning Indicator 7 Aid to Families with Dependent Children (AFDC) 8 Payer defined exemption Page 56

57 12. Prescriber Provider ID Qualifier Use Qualifier 12 for the Drug Enforcement Administration (DEA) Number for the prescriber 13. DUR/Professional Service Codes A B C Reason for service Professional Service code Result of Service 14. Basis of Cost Determination Blank Not specified 00 Not specified 01 AWP (average wholesale price) 02 Local Wholesale 03 Direct 04 EAC (Estimated Acquisition Cost) 05 Acquisition 06 MAC (Maximum Allowable Cost) 07 Usual and Customary (U&C) 09 Other 15. Provider Id Qualifier Use Qualifier 07 for the NCPDP/NABP number of the pharmacy 17. Other Payer ID Qualifier 99 Other - MDCH Carrier ID Page 57

58 Appendix C: MDCH Maintenance Drug List A maximum supply of 100 days is allowed for drugs in the following therapeutic classes. Certain drugs may have specific quantity limits, which supersede this list. See the MPPL at Select the link to Providers and then Drug Information. Therapeutic Class 05 Bile Therapy 09 Antiparkinson Agents 11 Psychostimulants/Antidepressants 15 Bronchodilators 32 Antimalarials 33 Antivirals 34 TB Preparations 48 Anticonvulsants 52 Mineralocorticoids 55 Thyroid Preparations 56 Anti-Thyroid Preparations 58 Diabetic Therapy 61 Estrogens 62 Progesterone 63 Oral Contraceptives 66 Cholesterol Reducers 67 Digestants 69 Enzymes 70 Rauwolfia Preparations 71 Other Hypotensives 72 Vasodilators: Coronary 73 Vasodilators: Peripheral 74 Digitalis Preparations 75 Xanthine Derivatives 76 Cardiovascular Preparations: Other 77 Anticoagulants 79 Diuretics Name Page 58

59 Therapeutic Class 80 Vitamins: Fat Soluble 81 Vitamins: Water Soluble 82 Multivitamin Preparations 83 Folic Acid Preparations 84 B Complex with Vitamin C 87 Electrolytes & Misc. Nutrients Name 88 Hematinics (with the exception of Darbepoetin, Epoetin, Filgrastim, and Pegfilgrastim) Page 59

60 Appendix D: Medicare Part B Covered Drugs After payment is received from Part B for individuals dually enrolled in Medicare and Medicaid, MDCH may pay the dual eligible s coinsurance up to the MDCH allowable reimbursement levels. As explained in the Section Program Specifications of the Michigan Pharmacy Claims Processing Manual, pharmacies must call the Technical Call Center to obtain override for the coinsurance payment. Examples of Part B covered drugs include, but are not limited to, the following products: Medicare Part B Covered Drugs Drug Name Busulfan Capecitabine Darboetin Alfa Epoetin Alfa Etoposide Mephalen Methotrexate Temozolomide Antihemophilic Factor IX Preparations Antihemophilic Factors Azathioprine Cyclophosphamide Cyclosporine Daclizumab Lymphocyte Immune Globulins Muromonab-CD3 Mycophenolate Sirolimus Tacrolimus Acetylcysteine Albuterol Albuterol/Ipratropium Combination Use Cancer Cancer Cancer Cancer Cancer Cancer Cancer Cancer Hemophilia Hemophilia Immunosuppressive Immunosuppressive Immunosuppressive Immunosuppressive Immunosuppressive Immunosuppressive Immunosuppressive Immunosuppressive Immunosuppressive Inhalation Inhalation Inhalation Page 60

61 Drug Name Bitoterol Budesonide Cromolyn Dornase Alpha Ipratropium Isoetharine Levalbuterol Metaproterenol Pentamidine Tobramycin Ventavis Avonex Dolasetron Dronabinol Graniseton Ondansetron Use Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Multiple Sclerosis Nausea/Cancer Nausea/Cancer Nausea/Cancer Nausea/Cancer Page 61

62 Appendix E: ProDUR E.1 ProDUR Problem Types Prospective Drug Utilization Review (ProDUR) encompasses the detection, evaluation, and counseling components of pre-dispensing drug therapy screening. The ProDUR system of First Health Services assists in these functions by addressing situations in which potential drug problems may exist. ProDUR performed prior to dispensing assists the pharmacists to ensure that their patients receive the appropriate medications. Because the First Health Services ProDUR system examines claims from all participating pharmacies, drugs that interact or are affected by previously dispensed medications can be detected. First Health Services recognizes that the pharmacists use their education and professional judgments in all aspects of dispensing. ProDUR is offered as an informational tool to aid the pharmacists in performing their professional duties. Listed below are all the ProDUR Conflict Codes within the First Health Services system for the Michigan Medicaid Program. Conflict Codes Description Disposition Comments DD Drug to Drug Interaction Deny Severity Level 1, alert only on others May be overridden by the provider at the POS using the NCPDP DUR override codes. ER Early Refill Deny Pharmacies must contact the First Health Services Technical Call Center ( ) to request an override. LR Late Refill Alert only TD Therapeutic Duplication Deny on selected therapeutic classes, alert only on others ID Duplicate Ingredient Alert only LD, HD PA PA Minimum/Maximum Daily Dosing Drug to Pediatric Precaution Drug to Geriatric Precaution Alert only Alert only on Severity Level 1 Alert only on Severity Level 1 May be overridden by a pharmacy at the POS using the NCPDP DUR override codes. Page 62

63 Conflict Codes Description Disposition Comments DC Drug to Inferred Disease Alert only on Severity Level 1 SR Prerequisite Drug Therapy Deny SX Drug to Gender Deny on Severity Levels 1 and 3 PP Plan Protocol Deny Anti-Ulcer Pharmacies should contact the First Health Services Clinical Call Center ( ) to request an override. Call Clinical Call center, after 102 days on high dose. See website for HD edit. E.2 Drug Utilization Review (DUR) s The following are the ProDUR edits that will deny for MDCH: Drug/Drug Interactions - (Severity level 1) - Provider overrides allowed. Early Refill - Contact Technical Call Center to request an override. Therapeutic Duplication - (selected therapeutic classes) - Provider overrides allowed. Drug to Gender - Severity 1 - Clinical Call Center may PA. Plan Protocol - Anti-Ulcer perquisite. NCPDP 88 DUR Reject Error Message Also note that the following ProDUR edits will return a warning message only (i.e., an override is not necessary). Late Refill Duplicate Ingredient Minimum/Maximum Daily Dosing Drug to Pediatric Precautions - (Severity Level 1) Drug to Geriatric Precautions - (Severity Level 1) Drug to Inferred Disease - (Severity Level 1) Therapeutic Duplication - (Selected Therapeutic Classes) Page 63

64 Provider overrides are processed on a per-claim (date of service only) basis. For quality of care purposes, pharmacists are required to retain documentation relative to these overrides. E.3 DUR Reason For Service The DUR Reason for Service is used to define the type of utilization conflict that was detected (NCPDP #439-E4). For MDCH, valid DUR Reason for Service codes are: DD Drug/Drug Interactions TD Therapeutic Duplication ER Early Refill SX Drug/Sex Restriction E4 NCPDP Message M/I DUR Conflict/Reason For Service Code E.4 DUR Professional Service The DUR Professional Service (previously Intervention Code ) is used to define the type of interaction or intervention that was performed by the pharmacist (NCPDP #440-E5). Valid DUR Professional Service Codes for the Michigan Medicaid Program are: 00 No Intervention CC Coordination Of Care M0 Prescriber Consulted PH Patient Medication History P0 Patient Consulted R0 Pharmacist Consulted Other Source E5 NCPDP Message M/I DUR Intervention/Professional Service Code Page 64

65 E.5 DUR Result of Service The DUR Result of Service (previously Outcome Code ) is used to define the action taken by the pharmacist in response to a ProDUR Reason for Service or the result of a pharmacist s professional service (NCPDP #441- E6). Valid DUR Result of Services for the Michigan Medicaid Program are: 1A Filled As Is, False Positive 1B Filled Prescription As Is 1C Filled With Different Dose 1D Filled With Different Directions 1F Filled With Different Quantity 1G Filled With Prescriber Approval 3B Recommendation Not Accepted 3C Discontinued Drug E6 NCPDP Message M/I DUR Outcome/Result Of Service Code Provider overrides are allowed on claims denied for REASON FOR SERVICE DD (Drug to Drug Interactions) or TD (Therapeutic Duplications). Pharmacies must submit the allowed Professional Service and Result of Service codes as listed above. If other values are submitted, the claim will continue to deny. Page 65

66 E.6 Prospective Drug Utilization Review (ProDUR) ER edit is hitting because of a LTC new admission or a re-admission and Level of Care = 02, 16, 55, or 56. Provider overrides PA by entering Submission Clarification Code field = 05. ER/Early Refill If the provider is trying to submit this override and the patient is NOT flagged with an ACTIVE LTC or Patient Attribute record the claim will continue to deny. If this situation occurs, please advise the provider of the following: When a Medicaid beneficiary is admitted to a facility, the facility is to submit a copy of the Facility Admission Notice (2565) to the local Family Independence Agency. Caseworker puts the LOC 02 on the system. Provider should get in touch with the facility to have them contact the FIA worker. This is the only way the enrollment record can be updated. TD/Therapeutic Duplication DD/Drug to Drug Contraindication Page 66

67 E.7 Drug/Drug Interactions & Therapeutic Duplication E.7.1 POS Override Procedure The First Health Services POS system provides online assistance for the dispensing pharmacist. Incoming drug claims are compared to a beneficiary s pharmacy claims history file to detect potential drug/drug interactions and therapeutic duplications. ProDUR denials are returned to the pharmacist when the POS process finds a SEVERITY LEVEL 1 problem as defined by First Data Bank. These denials are intended to assist the pharmacist awareness of beneficiary specific potential problems. These POS denials are not intended to replace the clinical judgment of the dispensing pharmacist. Use the attached override procedure when you as the dispensing pharmacist have made a beneficiary-specific clinical decision to override the POS denial/alert. For quality of care purposes, pharmacists are required to retain documentation relative to these overrides. Also, attached are the NCPDP specific codes that may be used in the respective Reason for Service, DUR Professional Service, and DUR Result of Service. Please note that each pharmacy s software may present the NCPDP standard override procedure fields differently. E.7.2 DUR Reason for Service The DUR Conflict Code is used to define the type of utilization conflict that was detected (NCPDP #439-E4). Valid DUR Conflict Codes for the Michigan Medicaid Program are: DD Drug/Drug Interactions TD Therapeutic Duplication If one of the above two options are not used, the following error message will be returned: E4 NCPDP Message M/I DUR Conflict/Reason For Service Code Page 67

68 Appendix F: POS Reject Codes & Messages After a pharmacy online claims submission, the First Health Services POS system returns messages that comply with NCPDP standards. Messages focus on Prospective Drug Utilization Review (ProDUR) and POS rejection codes, as explained in the next sections. F.1 Prospective Drug Utilization Review (ProDUR) Alerts If a pharmacy needs assistance interpreting ProDUR alert or denial messages from the First Health Service POS system, the pharmacy should contact the Technical Call Center Services at the time of dispensing. Refer to Appendix G: Directory at the end of this manual for contact information. The Technical 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. All ProDUR alert messages appear at the end of the claims adjudication transmission. The following table provides the format that is used for these alert messages. Table 11 - Record Format for ProDUR Alert Messages Format Reason For Service Code Severity Index Code Other Pharmacy Indicator Previous Date of Fill Quantity of Previous Fill Data Base Indicator Definitions Up to 3 characters - Code transmitted to pharmacy when a conflict is detected (e.g., ER, HD, TD, DD). 1 character - Code indicates how critical a given conflict is. 1 character - Indicates if the dispensing provider also dispensed the first drug in question. 1 = Your pharmacy 3 = Other pharmacy 8 characters - Indicates previous fill date of conflicting drug in YYYYMMDD format. 5 characters - Indicates quantity of conflicting drug previously dispensed. 1 character - Indicates source of ProDUR message. 1 = First DataBank 4 = Processor Developed Page 68

69 Other Prescriber Format Definitions 1 character - Indicates the prescriber of conflicting prescription. 0 = No Value 1 = Same Prescriber 2 = Other Prescriber F.2 Point-of-Sale Reject Codes and Messages The following table lists the rejection codes and explanations, possible B1, B2, B3 fields that may be related to denied payment, and possible solutions for pharmacies experiencing difficulties. All edits may not apply to this program. Pharmacies requiring assistance should call the First Health Services Technical Call Center. Refer to Appendix G: Directory at the end of this manual for contact information. Reject Code and Explanation M/I Means Missing/Invalid Table 12 - Point-of-Sale Reject Codes and Messages Possible # in Error Ø1 M/I Bin 1Ø1 Use ØØ9737 Possible Solutions Ø2 M/I Version Number 1Ø2 Version allowed = 5.1 Ø3 M/I Transaction Code 1Ø3 Transactions allowed = B1, B2, B3 Ø4 M/I Processor Control Number 1Ø4 Use PØØ8ØØ9737 Ø5 M/I Pharmacy Number 2Ø1 Use NCPDP # (formerly NABP) only and do not send Michigan Medicaid ID. Check with your software vendor to ensure appropriate number has been set up in your system. Your pharmacy must be an enrolled provider with Michigan Medicaid on the DOS. Ø6 M/I Group Number 3Ø1 Use MIMEDICAID only. Page 69

70 Reject Code and Explanation M/I Means Missing/Invalid Possible # in Error Possible Solutions Ø7 M/I Cardholder ID Number 3Ø2 Use Michigan Medicaid Beneficiary ID number only and do not use any other patient ID. Do not enter any dashes. Pharmacist should always examine a beneficiary s Medicaid ID card before services are rendered. It is the provider s responsibility to establish the identity of the beneficiary and to verify the effective date of coverage for the card presented. Ø8 M/I Person Code 3Ø3 Ø9 M/I Birthdate 304 The format is CCYYMMDD. 1C M/I Smoker/Non-Smoker Code 334 1E M/I Prescriber Location Code 467 1Ø M/I Patient Gender Code 3Ø5 Allowed values: 11 M/I Patient Relationship Code 3Ø6 12 M/I Patient Location 3Ø7 0 = Not specified 1 = Male 2 = Female Allowed value: 1 = Cardholder 13 M/I Other Coverage Code 3Ø8 Allowed values: 14 M/I Eligibility Clarification Code 3Ø9 ØØ = Not specified Ø1 = No other coverage identified Ø2 = Other coverage exists - payment collected Ø3 = Other coverage exist - this claim not covered Ø4 = Other coverage exists - payment not collected Ø5, Ø6, Ø7 and Ø8 = No longer allowed in the MDCH program Page 70

71 Reject Code and Explanation M/I Means Missing/Invalid Possible # in Error Possible Solutions 15 M/I Date of Service 4Ø1 The format is CCYYMMDD. 16 M/I Prescription/Service Reference Number 4Ø2 A future date is not allowed in this field. The format is NNNNNNN. 17 M/I Fill Number 4Ø3 Enter ØØ for a new prescription. Enter from a range of Ø1 to 99 for a refill prescription. 19 M/I Days Supply 4Ø5 The format is NNN. Enter the days supply. PRN is not allowed. 2C M/I Pregnancy Indicator 335 2E M/I Primary Care Provider ID Qualifier 2Ø M/I Compound Code 4Ø6 Allowed values: 468 Ø = Not specified 1 = Not a compound 2 = Compound See the Section Compound Claims of this manual. 21 M/I Product/Service ID 4Ø7 Use 11-digit NDC only. 22 M/I Dispense As Written (DAW)/Product Selection Code 23 M/I Ingredient Cost Submitted 4Ø8 4Ø9 Do not enter any dashes. DAW codes alone will not override MAC rates. DAW 2 is not allowed. Refer to Section Maximum Allowable Cost (MAC) of this manual. 25 M/I Prescriber ID 411 Use the prescriber s DEA ID number. Do not use any other number. 26 M/I Unit Of Measure 6ØØ If a prescriber does not have a DEA number, use ZZ ZZ is not allowed for scheduled controlled substances. Page 71

72 Reject Code and Explanation M/I Means Missing/Invalid Possible # in Error Possible Solutions 28 M/I Date Prescription Written 414 The format is CCYYMMDD. 29 M/I Number Refills Authorized 415 3A M/I Request Type 498-PA 3B M/I Request Period Date- Begin 498-PB 3C M/I Request Period Date-End 498-PC 3D M/I Basis Of Request 498-PD 3E 3F 3G 3H 3J 3K M/I Authorized Representative First Name M/I Authorized Representative Last Name M/I Authorized Representative Street Address M/I Authorized Representative City Address M/I Authorized Representative State/Province Address M/I Authorized Representative Zip/Postal Zone 498-PE 498-PF 498-PG 498-PH 498-PJ 498-PK 3M M/I Prescriber Phone Number 498-PM 3N M/I Prior Authorized Number Assigned 498-PY 3P M/I Authorization Number 5Ø3 3R 3S 3T Prior Authorization Not Required M/I Prior Authorization Supporting Documentation Active Prior Authorization Exists Resubmit At Expiration Of Prior Authorization 4Ø7 498-PP Page 72

73 3W 3X 3Y Reject Code and Explanation M/I Means Missing/Invalid Prior Authorization In Process Authorization Number Not Found Prior Authorization Denied Possible # in Error 5Ø3 Possible Solutions 32 M/I Level Of Service 418 Required when needed to identify emergency conditions (3 = Emergency). 33 M/I Prescription Origin Code M/I Submission Clarification Code 35 M/I Primary Care Provider ID 42Ø M/I Basis Of Cost M/I Diagnosis Code 424 4C 4E 4Ø M/I Coordination Of Benefits/Other Payments Count M/I Primary Care Provider Last Name Pharmacy Not Contracted With Plan On Date Of Service 41 Submit Bill To Other Processor Or Primary Payer 5C M/I Other Payer Coverage Type Ø None None 338 5E M/I Other Payer Reject Count 471 5Ø Non-Matched Pharmacy Number 2Ø1 Use NCPDP number only. Check the Date of Service. Call the Provider Enrollment Department, if necessary. Indicates the individual has other insurance coverage. See the Additional Message field for details, including Carrier ID, Carrier Name, Beneficiary Policy Number. Use NCPDP number only. Check beneficiary lock-in status. Page 73

74 Reject Code and Explanation M/I Means Missing/Invalid Possible # in Error Possible Solutions 51 Non-Matched Group Number 301 Use MIMEDICAID only. 52 Non-Matched Cardholder ID 302 Use Michigan 10-digit Medicaid Health Insurance Number (2 zeros in front of the 8-digit Beneficiary ID) only. 53 Non-Matched Person Code 3Ø3 54 Non-Matched Product/Service ID Number 55 Non-Matched Product Package Size 4Ø7 4Ø7 Do not use any other patient ID. Do not enter any dashes. Use 11-digit NDC. 56 Non-Matched Prescriber ID 411 Use the prescriber s DEA number. 58 Non-Matched Primary Prescriber 6C M/I Other Payer ID Qualifier 339 Use 99 = Other 421 If a prescriber does not have a DEA number, use ZZ ZZ is not allowed for controlled substances. 6E M/I Other Payer Reject Code 472 Required with Other Coverage Code 3 effective May 15, To be required with Other Coverage Code 1 in the future. 6Ø Product/Service Not Covered For Patient Age 61 Product/Service Not Covered For Patient Gender 62 Patient/Card Holder ID Name Mismatch 63 Institutionalized Patient Product/Service ID Not Covered 3Ø2, 3Ø4, 4Ø1, 4Ø7 3Ø2, 3Ø5, 4Ø7 31Ø, 311, 312, 313, 32Ø Page 74

75 Reject Code and Explanation M/I Means Missing/Invalid 64 Claim Submitted Does Not Match Prior Authorization Possible # in Error 2Ø1, 4Ø1, 4Ø4, 4Ø7, Patient Is Not Covered 3Ø3, 3Ø6 66 Patient Age Exceeds Maximum Age 67 Filled Before Coverage Effective 68 Filled After Coverage Expired 69 Filled After Coverage Terminated 3Ø3, 3Ø4, 3Ø6 4Ø1 4Ø1 4Ø1 Possible Solutions Use the Michigan 10-digit Medicaid Health Insurance Number (with 2 zeros in front of the 8-digit Beneficiary ID) only. Do not enter any dashes. Check the Date of Service. Check the Group Number. Use the Michigan 10-digit Medicaid Health Insurance Number (with 2 zeros in front of the 8-digit Beneficiary ID) only. Do not enter any dashes. Check the Date of Service. Check the Group Number. 7C M/I Other Payer ID 34Ø Submit valid 8-digit MI Medicaid Other Carrier ID. 7E M/I DUR/PPS Code Counter 473 7Ø Product/Service Not Covered 4Ø7 Use 11-digit NDC. Drug not covered. 71 Prescriber Is Not Covered Primary Prescriber Is Not Covered Refills Are Not Covered 4Ø2, 4Ø3 74 Other Carrier Payment Meets Or Exceeds Payable 4Ø9, 41Ø, Prior Authorization Required 462 Use 11-digit NDC. Drug requires PA. Page 75

76 Reject Code and Explanation M/I Means Missing/Invalid Possible # in Error Possible Solutions 76 Plan Limitations Exceeded 4Ø5, 442 Check days supply and metric decimal quantity. 77 Discontinued Product/Service ID Number 4Ø7 78 Cost Exceeds Maximum 4Ø7, 4Ø9, 41Ø, 442 Use the 11-digit NDC. NDC is obsolete. 79 Refill Too Soon 4Ø1, 4Ø3, 4Ø5 75% days supply of previous claim has not been utilized. Logic includes all claims (batch, POS, and paper). 8C M/I Facility ID 336 8E M/I DUR/PPS Level Of Effort 474 8Ø Drug-Diagnosis Mismatch 4Ø7, Claim Too Old 4Ø1 Check the Date of Service. 82 Claim Is Post-Dated 4Ø1 Check the Date of Service. 83 Duplicate Paid/Captured Claim 84 Claim Has Not Been Paid/Captured 85 Claim Not Processed None 86 Submit Manual Reversal None 2Ø1, 4Ø1, 4Ø2, 4Ø3, 4Ø7 2Ø1, 4Ø1, 4Ø2 87 Reversal Not Processed None Service Provider Number (NCPDP ID), Date of Service, National Drug Code (NDC), and Rx Number must equal original claim. 88 DUR Reject Error 89 Rejected Claim Fees Paid 9Ø Host Hung Up Processing host did not accept transaction or did not respond within time out period. Host disconnected before session completed. 91 Host Response Error Response not in appropriate format to be displayed. Page 76

77 Reject Code and Explanation M/I Means Missing/Invalid 92 System Unavailable/Host Unavailable *95 Time Out *96 Scheduled Downtime *97 Payer Unavailable *98 Connection To Payer Is Down Possible # in Error Possible Solutions Processing host did not accept transaction or did not respond within time out period. 99 Host Processing Error Do not re-transmit claim(s). AA AB AC AD AE AF AG AH AJ AK Patient Spend-down Not Met Date Written Is After Date Filled Product Not Covered Non- Participating Manufacturer Billing Provider Not Eligible To Bill This Claim Type QMB (Qualified Medicare Beneficiary)-Bill Medicare Patient Enrolled Under Managed Care Days Supply Limitation For Product/Service Unit Dose Packaging Only Payable For Nursing facility Beneficiaries Generic Drug Required M/I Software Vendor/Certification ID 11Ø AM M/I Segment Identification 111 A9 M/I Transaction Count 1Ø9 BE B2 M/I Professional Service Fee Submitted M/I Service Provider ID Qualifier 477 2Ø2 Use Ø7 = NCPDP Provider ID Page 77

78 Reject Code and Explanation M/I Means Missing/Invalid Possible # in Error Possible Solutions CA M/I Patient First Name 31Ø Check the patient s first name. CB M/I Patient Last Name 311 Check the patient s last name. CC M/I Cardholder First Name 312 CD M/I Cardholder Last Name 313 CE M/I Home Plan 314 CF M/I Employer Name 315 CG M/I Employer Street Address 316 CH M/I Employer City Address 317 CI CJ M/I Employer State/Province Address M/I Employer Zip Postal Zone CK M/I Employer Phone Number 32Ø CL M/I Employer Contact Name 321 CM M/I Patient Street Address 322 CN M/I Patient City Address 323 CO M/I Patient State/Province Address 324 CP M/I Patient Zip/Postal Zone 325 CQ M/I Patient Phone Number 326 CR M/I Carrier ID 327 CW M/I Alternate ID 33Ø CX M/I Patient ID Qualifier 331 CY M/I Patient ID 332 CZ M/I Employer ID 333 DC DN DQ M/I Dispensing Fee Submitted M/I Basis Of Cost Determination M/I Usual And Customary Charge DR M/I Prescriber Last Name 427 Page 78

79 Reject Code and Explanation M/I Means Missing/Invalid DT M/I Unit Dose Indicator 429 DU M/I Gross Amount Due 43Ø DV DX M/I Other Payer Amount Paid M/I Patient Paid Amount Submitted Possible # in Error Possible Solutions 431 Enter the amount received from other payer(s) for this claim. 433 DY M/I Date Of Injury 434 DZ M/I Claim/Reference ID 435 EA EB EC ED EE EF EG EH EJ EK EM EN M/I Originally Prescribed Product/Service Code M/I Originally Prescribed Quantity M/I Compound Ingredient Component Count M/I Compound Ingredient Quantity M/I Compound Ingredient Drug Cost M/I Compound Dosage Form Description Code M/I Compound Dispensing Unit Form Indicator M/I Compound Route Of Administration M/I Originally Prescribed Product/Service ID Qualifier M/I Scheduled Prescription ID Number M/I Prescription/Service Reference Number Qualifier M/I Associated Prescription/Service Reference Number Ø Page 79

80 EP Reject Code and Explanation M/I Means Missing/Invalid M/I Associated Prescription/Service Date Possible # in Error 457 ER M/I Procedure Modifier Code 459 ET M/I Quantity Prescribed 46Ø EU EV EW EX M/I Prior Authorization Type Code M/I Prior Authorization Number Submitted M/I Intermediary Authorization Type ID M/I Intermediary Authorization ID Possible Solutions 461 Required when needed to identify designated prior authorization and/or override conditions. Refer to the First Health Services Pharmacy Claims Processing Manual for details EY M/I Provider ID Qualifier 465 EZ M/I Prescriber ID Qualifier 466 Use 12 = DEA E1 E3 M/I Product/Service ID Qualifier M/I Incentive Amount Submitted E4 M/I Reason For Service Code 439 Refer to Section E.3 - DUR Reason For Service of this manual. E5 M/I Professional Service Code 44Ø Refer to Section E.4 - DUR Professional Service of this manual. E6 M/I Result Of Service Code 441 Refer to Section E5 - DUR Result of Service of this manual. E7 M/I Quantity Dispensed 442 The correct format is 9(7).999 E8 M/I Other Payer Date 443 E9 M/I Provider ID 444 FO M/I Plan ID 524 GE M/I Percentage Sales Tax Amount Submitted 482 Page 80

81 HA HB HC Reject Code and Explanation M/I Means Missing/Invalid M/I Flat Sales Tax Amount Submitted M/I Other Payer Amount Paid Count M/I Other Payer Amount Paid Qualifier Possible # in Error HD M/I Dispensing Status 343 HE HF HG M/I Percentage Sales Tax Rate Submitted M/I Quantity Intended To Be Dispensed M/I Days Supply Intended To Be Dispensed H1 M/I Measurement Time 495 H2 M/I Measurement Dimension 496 H3 M/I Measurement Unit 497 H4 M/I Measurement Value 499 H5 M/I Primary Care Provider Location Code 469 H6 M/I DUR Co-Agent ID 476 H7 H8 H9 JE J9 M/I Other Amount Claimed Submitted Count M/I Other Amount Claimed Submitted Qualifier M/I Other Amount Claimed Submitted M/I Percentage Sales Tax Basis Submitted M/I DUR Co-Agent ID Qualifier Ø KE M/I Coupon Type 485 M1 Patient Not Covered In This Aid Category Possible Solutions Page 81

82 M2 M3 M4 M5 M6 M7 M8 Reject Code and Explanation M/I Means Missing/Invalid Beneficiary Locked In Host PA/MC Error Prescription/Service Reference Number/Time Limit Exceeded Requires Manual Claim Host Eligibility Error Host Drug File Error Host Provider File Error ME M/I Coupon Number 486 MZ Error Overflow NE M/I Coupon Value Amount 487 NN PA PB Transaction Rejected At Switch Or Intermediary PA Exhausted/Not Renewable Invalid Transaction Count For This Transaction Code PC M/I Claim Segment 111 PD M/I Clinical Segment 111 PE M/I COB/Other Payments Segment Possible # in Error 1Ø3, 1Ø9 111 PF M/I Compound Segment 111 PG M/I Coupon Segment 111 PH M/I DUR/PPS Segment 111 PJ M/I Insurance Segment 111 PK M/I Patient Segment 111 PM M/I Pharmacy Provider Segment 111 PN M/I Prescriber Segment 111 PP M/I Pricing Segment 111 Possible Solutions Page 82

83 PR PS PT PV Reject Code and Explanation M/I Means Missing/Invalid M/I Prior Authorization Segment M/I Transaction Header Segment M/I Workers Compensation Segment Non-Matched Associated Prescription/Service Date Possible # in Error PW Non-Matched Employer ID 333 PX Non-Matched Other Payer ID 34Ø PY PZ P1 P2 P3 P4 Non-Matched Unit Form/Route Of Administration Non-Matched Unit Of Measure To Product/Service ID Associated Prescription/Service Reference Number Not Found Clinical Information Counter Out Of Sequence Compound Ingredient Component Count Does Not Match Number of Repetitions Coordination of Benefits/Other Payments Count Does Not Match Number Of Repetitions 451, 452, 6ØØ 4Ø7, 6ØØ P5 Coupon Expired 486 P6 P7 Date Of Service Prior To Date of Birth Diagnosis Code Count Does Not Match Number Of Repetitions 3Ø4, 4Ø1 491 Possible Solutions Page 83

84 P8 P9 RA RB RC RD RE RF RG RH RJ RK RM RN Reject Code and Explanation M/I Means Missing/Invalid DUR/PPS Code Counter Out of Sequence is Non-Repeatable PA Reversal Out Of Order Multiple Partials Not Allowed Different Drug Entity Between Partial & Completion Mismatched Cardholder/Group ID-Partial To Completion M/I Compound Product ID Qualifier Improper Order Of Dispensing Status Code On Partial Fill Transaction M/I Associated Prescription/service Reference Number On Completion Transaction M/I Associated Prescription/Service Date On Completion Transaction Associated Partial Fill Transaction Not On File Partial Fill Transaction Not Supported Completion Transaction Not Permitted With Same Date Of Service As Partial Transaction Plan Limits Exceeded On Intended Partial Fill Values Possible # in Error 473 3Ø1, 3Ø Ø1 344, 345 Possible Solutions Page 84

85 RP RS RT RU R1 R2 R3 R4 R5 R6 R7 R8 Reject Code and Explanation M/I Means Missing/Invalid Out Of Sequence P Reversal On Partial Fill Transaction M/I Associated Prescription/Service Date On Partial Transaction M/I Associated Prescription/Service Reference Number On Partial Transaction Mandatory Data Elements Must Occur Before Optional Data Elements In A Segment Other Amount Claimed Submitted Count Does Not Match Number of Repetitions Other Payer Reject Count Does Not Match Number of Repetitions Procedure Modifier Code Count Does Not Match Number of Repetitions Procedure Modifier Code Invalid For Product/Service ID Product/Service ID Must Be Zero When Product/Service ID Qualifier Equals Ø6 Product/Service Not Appropriate For This Location Repeating Segment Not Allowed In Same Transaction Syntax Error Possible # in Error , 48Ø 471, , 459 4Ø7, 436, 459 4Ø7, 436 3Ø7, 4Ø7, 436 Possible Solutions Page 85

86 R9 SE Reject Code and Explanation M/I Means Missing/Invalid Value In Gross Amount Due Does Not Follow Pricing Formulae M/I Procedure Modifier Code Count Possible # in Error 43Ø 458 TE M/I Compound Product ID 489 UE M/I Compound Ingredient Basis Of Cost Determination 49Ø VE M/I Diagnosis Code Count 491 WE M/I Diagnosis Code Qualifier 492 XE M/I Clinical Information Counter 493 ZE M/I Measurement Date 494 Possible Solutions Page 86

87 Appendix G: Directory Contact/Topic Contact Numbers Technical Call Center /7/365 Clinical Call Center 7:00 a.m. 7:00 p.m. Monday - Friday (After hours calls rollover to Technical Call Center) Beneficiary Inquiries 24/7/365 Provider Relations Department 8:15 a.m. - 4:45 p.m. Monday - Friday MDCH Pharmacy Fax: or Mailing, & Web Addresses Purpose/Comments Pharmacy calls for: ProDUR questions Non-clinical prior authorization & early refills Overrides for the Beneficiary Lock-In Program Fax: or Fax: First Health Services 4300 Cox Road Glen Allen, VA First Health Services Provider Relations 4300 Cox Road Glen Allen, Virginia Questions regarding payer specifications Etc. Prescriber calls for: Prior authorization (PA) on non-preferred products PA for other clinical reasons Etc. Pharmacy calls for: Dollar amount limits Medicare Part B coinsurance Etc. To respond to inquiries on general pharmacy coverages, the MDCH Beneficiary Help Line is available at for eligibility issues. To request EFT payments To request a paper copy of Pharmacy Claims Processing Manual Page 87

88 Contact/Topic Contact Numbers Mailing, & Web Addresses Purpose/Comments Enrollment To enroll as an MDCH pharmacy Enrollment forms are at: - Select the link to Providers and Provider Forms Electronic Media Claims Coordinator 8:00 a.m. - 9:00 p.m. Monday - Friday (Except holidays) Fax: Electronic Media Claims (EMC) First Health Services Media Control/Michigan EMC Processing Unit 4300 Cox Road Glen Allen, VA [email protected] To ask questions on: File Transfer Protocols (FTP) claims submission Electronic remittance advices Directory Assistance 8:00 a.m. - 5:00 p.m. Monday - Friday To locate an employee at First Health Services Vendor Software Certification & Testing 8:00 a.m. - 5:00 p.m. Monday - Friday [email protected] To confirm a software s vendor certification For software vendors, to obtain certification and test billing transaction sets Universal Claim Forms (UCFs) NCPDP 7:00 a.m. - 5:00 p.m. MT Monday - Friday Moore Wallace 1800 Lake Way Drive Suite 118 Lewisville, TX Fax: National Council for Prescription Drug Programs 9240 East Raintree Drive Scottsdale, AZ To obtain UCFs To obtain a NCPDP # or update addresses Page 88

89 Web Addresses First Health Services MDCH MAC Managers To view the Michigan Medicaid Provider Manual, select the following links: Providers and the Information for Medicaid Providers. Refer to the Directory Appendix within the Michigan Medicaid Provider Manual for contact information and other useful MDCH websites. Mailing Addresses For Claims Submission Paper Claims (UCFs) First Health Services Corp. Michigan Paper Claims Processing Unit P.O. Box C Richmond, VA Electronic Media Claims (EMC) (Tapes/Cartridges) Media Control/Michigan EMC Processing Unit 4300 Cox Road Glen Allen, VA Additional Phone Numbers National Data Corporation (NDC) WebMD QS Page 89