hb```+@(1Q(b!V R;Wyjn~u~kw~}CI @B 8F8CEVR,r@Zk0226H;)maVf\p@j053s0OIk5v X u cs. Required on all COB claims with Other Coverage Code of 2. For Transaction Code of "B2" in the Response Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Members within this eligibility category will not be subject to utilization management policies as outlined in the Appendix P, Preferred Drug List (PDL) or Appendix Y. Required when necessary to identify the Patient's portion of the Sales Tax. It is used for multi-ingredient prescriptions, when each ingredient is reported. 03 = National Drug Code (NDC) - Formatted 11 digits (N). All claims for incremental and subsequent fills require valid values in the following fields: Please note: if a pharmacy submits a claim for a non-Schedule II medication and includes a value for quantity prescribed, it must be a valid value. Required if Patient Pay Amount (505-F5) includes deductible. Health First Colorado is temporarily deferring medication prior authorization (PA) requirements for members on all medications for which there is an existing 12-month PA approval in place. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Required when any other payment fields sent by the sender. 1-5 = Refill number - Number of the replenishment, 8 = Substitution Allowed-Generic Drug Not Available in Marketplace, 1-99 = Authorized Refill number - with 99 being as needed, refills unlimited, 8 = Process Compound For Approved Ingredients. Pharmacy claims must be submitted electronically and within the timely filing period, with few exceptions. WebAWP Reimbursement Basis - Complete the following tables using the drug reimbursement that your organization is willing to guarantee on a dollar-for-dollar basis for each year of the contract. Required when necessary for patient financial responsibility only billing.
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