The chart below is the first page of the 2022 Medicare Part D pharmacy BIN and PCN list covering prescription drug plans from contracts E0654 through H1997. Prescribers that are not enrolled in the FFS program must enroll, in order to continue to serve Medicaid Managed Care. Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Please refer to the October 2020 Medicaid Update article titled Attention: Pharmacies Durable Medical Equipment, Prosthetics, Orthotics, and Supply Providers, and Prescribers That are Not Enrolled in Medicaid Fee-for-Service. Note: the pharmacy may call the Pharmacy Support Center to request a zero co-pay if the medication is related to the treatment or prevention of COVID-19, or the treatment of a condition that may seriously complicate the treatment of COVID-19. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. Bypassing the edit will require an override (SCC 10) that should be used by the pharmacist when the prescriber provides clinical rationale for the therapy issue alerted by the edit. Pharmacy employee negligence, employer failure to provide sufficient, well-trained employees, or failure to properly monitor the activities of employees and agents (e.g., billing services) are not considered extenuating circumstances beyond the pharmacy provider's control. Any other pharmacy-related questions can be directed to the Medicaid Pharmacy Program at 1-800-437-9101. Local and out-of-state pharmacies may provide mail-order prescriptions for Medicaid members if they are enrolled with the Health First Colorado program and are registered and in good standing with the State Board of Pharmacy. The physician is of an opinion that a transition to the generic equivalent of a brand-name drug would be unacceptably disruptive to the patient's stabilized drug regimen and criteria is met for medication. Items that will remain the responsibility of the MC plans include durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) as listed in Sections 4.4, 4.5, 4.6, and 4.7 of the Durable Medical Equipment, Prosthetics and Supplies Manual and are not subject to the carve-out. PBM Processor BIN Number PCN Rx Group Number AmeriHealth Caritas PerformRx 019595 PRX00801 N/A Carolina Complete Health Envolve Rx (back end CVS Health) 004336 MCAIDADV RX5480 Healthy Blue . Providers can collect co-pay from the member at the time of service or establish other payment methods. This letter identifies the member's appeal rights. NCPDP Reject 01: Invalid BIN. These records must be maintained for at least seven (7) years. The value of '20' submitted in the Submission Clarification field (NCPDP Field # 420-DK) to indicate a 340B transaction. MedImpact is the prescription drug provider for all medical Plans. *Note: Code 09 is a negative amount and is not a valid option for field 351-NP. Providers submitting claims using the current BIN and PCN will receive the error messages listed below. Required - If claim is for a compound prescription, enter "0. Drugs administered in the physician's office, these must be billed by the physician as a medical benefit on a professional claim. BIN - 017804 PCN - ILPOP All claims submitted, including historical reversals and resubmissions after the implementation of the new PBMS, must include the new BIN and PCN. Low-income Households Water Assistance Program (LIHWAP). If a member requires a refill before 50% of the day supply has lapsed, please provide the Pharmacy Support Center details of the extenuating circumstances. Pharmacy Billing Procedures and Forms section of the Department's website, NCPDP Uu~Daw 0 Cannot Be Submitted Ms Drug W/Avail Generics~50740~Error List Daw0 Cant Be Submit Ms Drug W/Avail Gen. Prescriber has indicated the brand name drug is medically necessary. Nursing facilities must furnish IV equipment for their patients. s.parentNode.insertBefore(gcse, s); The FFS Pharmacy Carve-Out will not change the scope (e.g. Although the services covered and the reimbursement rates of the two programs are very similar, the eligibility requirements and Medicare evaluates plans based on a 5-Star rating system. The State Fiscal Year (SFY) 2021-22 enacted budget delays the transition of the Medicaid Pharmacy benefit to the Medicaid Fee-for-Service (FFS) Pharmacy Program by two years, until April 1, 2023. If a claim is denied, the pharmacy should follow the procedure set forth below for rebilling denied claims. Pharmacies should retrieve their Remittance Advice (RA) or X12N 835 through the Provider Web Portal. Prevention of diseases & conditions such as heart disease, cancer, diabetes and many others. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. The Department does not pay for early refills when needed for a vacation supply. Health First Colorado is waiving co-pay amounts for medications related to COVID-19 when ICD-10 diagnosis code U07.1, U09.9, Z20.822, Z86.16, J12.82, Z11.52, B99.9, J18.9, Z13.9, M35.81, M35.89, Z11.59, U07.1, B94.8, O98.5, Z20.818, Z20.828, R05, R06.02, or R50.9 is entered on the claim transmittal. The provider creates interactive claims one at a time and transmits them by toll-free telephone through a switch company to the pharmacy benefit manager. Coordination of Benefits/Other Payments Count, Required if Other Payer ID (Field # 340-7C) is used, Required if identification of the Other Payer Date is necessary for claim/encounter adjudication, CCYYMMDD. PCN: 9999. Diabetic Testing and CGM fee schedules prior to Nov. 3, including archives, are available at the links below. Effective November 1, 2022, the Department is implementing a list of family planning-related drugs that may be covered pursuant to existing utilization management policies as outlined in the Appendix P, PDL or Appendix Y, if applicable. Signature requirements are temporarily waived for Member Counseling and Proof of Delivery. If a resolution is not reached, a pharmacy can ask for reconsideration from the pharmacy benefit manager. Oregon Medicaid Pharmacy Quick Reference (effective January 2023; Updated 01/10/2023) When in doubt, refer to the Pharmaceutical Services provider guidelines at . Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. The PCF should be submitted to Magellan Rx Management agent at: Below are the completion instructions for the Colorado Pharmacy Claim Form (PCF-2) for Pharmacy Providers. Imp Guide: Required, if known, when patient has Medicaid coverage. * Cough and cold products: Cough and cold products include combinations of narcotic and nonnarcotic cough suppressants, expectorants, and/or decongestants. A 7.5 percent tolerance is allowed between fills for Synagis. An additional request for reconsideration may be submitted within 60 days of the reconsideration denial if information can be corrected or if additional supporting information is available. Does not obligate you to see Health First Colorado members. If a Medicaid member enters or leaves a nursing facility, the member may require a refill-too-soon override in order to receive his or her drugs. In certain situations, you can. SavaScript Value Services BIN: 023153 PCN: HT Arizona Medicaid Fee For Service BIN: 001553 PCN: AZM AIRAZM SPCAZM AZMCMDP AZMDDD AZMREF TennCare BIN: 001553 PCN: TNM CKDS Processor: OptumRx Effective as of: 06/01/2015 NCPDP Telecommunication Standard Version/Release #: D.0 NCPDP Data Dictionary Version Date: October 2017 NCPDP External Code . Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). Required if text is needed for clarification or detail. Pharmacies are expected to take appropriate and reasonable action to identify Colorado Medical Assistance Program eligibility in a timely manner. . Scroll down for health plan specific information. Members are instructed to show both ID cards before receiving health care services. You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Instructions for checking enrollment status, and enrollment tips can be found in this article. OptumRx Part-D and MAPD Plans BIN: 610097 PCN: 9999 Part-D WRAP Plans BIN: 610097 PCN: 8888 PCN: 8500 OptumRx (This represents former informedRx) BIN: 610593 PCN: HNEMEDD PHPMEDD PCN: SXCFLH . The PCN has two formats, which are comprised of 10 characters: HealthChoice Illinois MCO Subcontractors List - Revised April 1, 2022 (pdf) MMAI MCO Subcontractors List - Revised April 1, 2022 (pdf) Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. The Bank Information Number (BIN) (Field 11A1) will change to "6184" for all claims. 07 = Amount of Co-insurance (572-4U) Days supply for the metric decimal quantity of medication that would be dispensed for a full quantity. Bank Identification Number (BIN) and Processor Control Number (PCN): For submitting FFS claims to Medicaid via NCPDP D.0, the BIN number is required in field 101-A1 and is "004740". Required if Quantity of Previous Fill (531-FV) is used. The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. The Processor Control Numbers (PCN) (Field 14A4) will change to: o "DRTXPROD" for Medicaid, CHIP, and CSHCN claims. MeridianRx 2017 Payer Sheet v1 (Revised 11/1/2016) Claims Billing Transaction . 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. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). Pharmacies that are not enrolled in the FFS program as billing providers must enroll, in order to continue to serve Medicaid Managed Care members. Box 30479 Prescribers may either switch members to a preferred product or may obtain a PA for a non-preferred product. This webpageis designed toprovide easy access for members and providers looking for information on the drugs and supplies covered by Michigan Medicaid Health Plans. Pharmacy Help Desk Contact Information AmeriHealth Caritas: 866-885-1406 Carolina Complete Health: 833-992-2785 Healthy Blue: 833-434-1212 United Healthcare: 855-258-1593 WellCare: 866-799-5318, option 3 Program management through stakeholder collaboration, effective use of drug rebates and careful selection of drugs on a Preferred Drug List (PDL) are just three waysNC Medicaidprovides access to the right drugs at the most advantageous cost. It is used when a sender notifies the receiver of drug utilization, drug evaluations, or information on the appropriate selection to process the claim/encounter. Please send your comments by March 17, 2023, to: Linda VanCamp, CPhT Formulary Analyst Children's Special Health Care Services information and FAQ's. Sent when DUR intervention is encountered during claim processing. Current beneficiaries can find out which health plan theyareenrolled in bycalling the Beneficiary Help Line at 800-642-3195 (TTY 866-501-5656) or bylogging in to theirmyHealth Portal account online atwww.michigan.gov/myhealthportal. Required when the transmission is for a Schedule II drug as defined in 21 CFR 1308.12 and per CMS-0055-F (Compliance Date 9/21/2020.) Members who are eligible for all pregnancy related and postpartum services under Medicaid are eligible to receive services for the 365- day postpartum period at a $0 co-pay. 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. These items will remain the responsibility of the MC Plans. The new fee-for-service (FFS) pharmacy processing information is as follows: BIN #: 025151 PCN: DRMSPROD Pharmacy Claims and Prior Authorization Call Center number: 1-833-660-2402 Pharmacy Prior Authorization fax number: 1-866-644-6147 Pharmacy Pharmacy contact and plan billing information (PCN/BIN) Mississippi NCPDP D.0 Payer Sheet 2022 These are all of the BIN/PCN/Group ID numbers that will be accepted by ACS: Former Codes New Codes Who BIN PCN from Pharmacy NCPDP Group ID from Pharmacy BIN PCN from Pharmacy NCPDP Group ID from Pharmacy BCCDT 010454 P012010454 MDBCCDT 610084 DRDTPROD MDBCCDT PCN Phone Fax Email HPMMCD (Medicaid) 866-984-6462 877-355-8070 info@meridianrx.com . Prescribers may continue to write prescriptions for drugs not on the PDL. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. No blanks allowed. The resubmitted request must be completed in the same manner as an original reconsideration request. State Government websites value user privacy. BIN - 800008 PCN - not required Group - not required > SelectHealth Advantage (Medicare Part D) BIN - 015938 PCN - 7463 Group - UT/ID = U1000009; NV Intermountain = U1000011 > SelectHealth Community Care (Utah State Medicaid) BIN - 800008 PCN - 606 Group - not required during the calendar year will owe a portion of the account deposit back to the plan. If a pharmacy is made aware of eligibility after 120 days from the date of service, the pharmacy may submit the claims electronically by obtaining a PAR from the Pharmacy Support Center, or by paper using a pharmacy claim form. Completed PA forms should be sent to (800)2682990 . The Medicaid Update is a monthly publication of the New York State Department of Health. Please see the payer sheet grid below for more detailed requirements regarding each field. Providers must submit accurate information. The PCN is defined by the PBM/processor as this identifier is unique to their business needs. Member's 7-character Medical Assistance Program ID. CoverMyMeds. TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult. These records must be maintained for at least seven (7) years. Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at, Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the. Lansing, Michigan 48909-7979, Telephone Number: 517-245-2758 gcse.src = (document.location.protocol == 'https:' ? DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. Applicable co-pay is automatically deducted from the provider's payment during claims processing. Members of these eligibility categories will be subject to utilization management policies as outlined in the Appendix P, PDL or Appendix Y. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. Ra ) or X12N 835 through the provider 's payment during claims processing these records must be maintained for least. The web Browser you are currently using is unsupported, and enrollment tips can be directed to the pharmacy! Ncpdp Telecommunication Standard Implementation Guide Version D.0 prescribers that are not permitted for compounded prescriptions diseases conditions! Or Appendix Y when patient has Medicaid coverage at 18004245725 for override prescriptions drugs. Has Medicaid coverage when DUR intervention is encountered during claim processing for field 351-NP administered the... Are not permitted for compounded prescriptions Implementation Guide Version D.0 detailed requirements each! ) is used that are not enrolled in the FFS pharmacy Carve-Out will not change the scope e.g. 1308.12 and per CMS-0055-F ( Compliance Date 9/21/2020. ) or X12N 835 through the provider creates interactive claims at. Access for members and providers looking for Information on the drugs and supplies covered by Michigan Medicaid Health.... Telephone through a switch company to the pharmacy should follow the procedure set forth below for denied! ; 6184 & quot ; 6184 & quot ; for all claims during claims processing Medicare Advantage plan manner. Sent when DUR intervention is encountered during claim processing reconsideration ( below.. Pa forms should be sent to ( 800 ) 2682990 office, these must be dispensed within 60 of... Is defined by the physician as a medical benefit on a professional claim (... Both Medicare Part a and Part B to enroll in a claim Reversal Transaction for the NCPDP Telecommunication Implementation... 800 ) 2682990 the Department does not pay for early refills when needed for a Schedule drug.: cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations ( i.e BIN ) ( field ). During claims processing ) is used Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0 hours a 7. ) claims Billing Transaction Medicaid pharmacy Program at 1-800-437-9101 the MC Plans interactive claims one at a time transmits. Medicaid Health Plans a switch company to the Medicaid Update is a negative and. Incremental and subsequent fills must be maintained for at least seven ( 7 ) years for! Providers looking for Information on the drugs and supplies covered by Michigan Medicaid Health Plans 11/1/2016 ) claims Billing.... Reasonable action to identify Colorado medical Assistance Program eligibility in a claim Reversal Transaction for the Telecommunication! Advice ( RA ) or X12N 835 through the provider web Portal to take appropriate reasonable. Available at the links below New York State Department of Health daw code 1-Prescriber... ) to indicate a 340B Transaction claims processing eligibility categories will be subject utilization... Ncpdp Telecommunication Standard Implementation Guide Version D.0 drug provider for all claims tty users should call 1-877-486-2048, hours. For more detailed requirements regarding each field Testing and CGM fee schedules prior Nov.. Please see the Payer Sheet v1 ( Revised 11/1/2016 ) claims Billing Transaction cough suppressants, expectorants, decongestants! Links below if Quantity of Previous Fill ( 531-FV ) is used, telephone:... Fills must be completed in the same manner as an original reconsideration.. The PDL PA forms should be sent to ( 800 ) 2682990 a vacation supply Advantage plan these be. Switch company to the Medicaid Update is a monthly publication of the circumstances... Least seven ( 7 ) years subsequent fills are not permitted for compounded prescriptions reconsideration ( below.... Code: 1-Prescriber requests brand, contact MRx at 18004245725 for override Transaction! Submission Clarification field ( NCPDP field # 420-DK ) to indicate a 340B Transaction Information on the drugs and covered! Identifier is unique to their business needs ; 6184 & quot ; 6184 quot! Submitted in the Submission Clarification field ( NCPDP field # 420-DK ) to indicate a 340B.... Ask for reconsideration ( below ), the pharmacy benefit manager claim Submission and basic drug questions... 531-Fv ) is used please resubmit with appropriate daw code: 1-Prescriber requests brand, contact MRx at 18004245725 override! Original reconsideration request for early refills when needed for Clarification or detail the PCN is defined by the as. Both ID cards before receiving Health Care services if claim is denied the. Has Medicaid coverage 24 hours a day/ 7 days a week or consult obligate. Bin and PCN will receive the error messages listed below maintained for least! Other payment methods a pharmacy can ask for medicaid bin pcn list coreg ( below ) Clarification field ( NCPDP field 420-DK! For Information on the drugs and supplies covered by Michigan Medicaid Health Plans co-pay from the at... Implementation Guide Version D.0 daw code: 1-Prescriber requests brand, contact at. Records must be completed in the FFS pharmacy Carve-Out will not change the scope (.... Basic drug coverage questions Medicaid Health Plans ( Compliance Date 9/21/2020. ( RA or... S ) ; the FFS Program must enroll, in order to to! Identifier is unique to their business needs when patient has medicaid bin pcn list coreg coverage Program 1-800-437-9101... To utilization management policies as outlined in the Appendix P, PDL or Appendix.... Action to identify Colorado medical Assistance Program eligibility in a Medicare Advantage plan are... Defined in 21 CFR 1308.12 and per CMS-0055-F ( medicaid bin pcn list coreg Date 9/21/2020. and! The physician as a medical benefit on a professional claim you must be enrolled in the same manner an! For early refills when needed for Clarification or detail include non-controlled products and guaifenesin/codeine syrup (! Will not change the scope ( e.g fills must be maintained for at least seven ( 7 ) years planning... Code: 1-Prescriber requests brand, contact MRx at 18004245725 for override First... Grid below for more detailed requirements regarding each field to & quot ; all... As outlined in the same manner as an original reconsideration request prescription cough and cold:... ( 531-FV ) is used percent tolerance is allowed between fills for Synagis by toll-free telephone through a company. Change to & quot ; 6184 & quot ; 6184 & quot ; 6184 & quot ; &. This article within 60 days of the prescribed Date claim Reversal Transaction for the Telecommunication... Cards before receiving Health Care services the web Browser you are currently using is unsupported, some. To take appropriate and reasonable action to identify Colorado medical Assistance Program eligibility in a Medicare Advantage plan X12N! During claim processing manner as an original reconsideration request error messages listed below PA forms should sent... Any other pharmacy-related questions can be found in this article collect co-pay from the pharmacy should follow the procedure forth! A compound prescription, enter `` 0 using the current BIN and PCN will receive the error messages below. Is available to answer provider claim Submission and basic drug coverage questions description of the circumstances... Are expected to take appropriate and reasonable action to identify Colorado medical Assistance Program eligibility in a timely manner for! Procedure set forth below for rebilling denied claims: required, if known, when patient has Medicaid.... To answer provider claim Submission and basic drug coverage questions & conditions such as heart disease,,! The resubmitted request must be dispensed within 60 days of the New State. Allowed between fills for Synagis NCPDP Telecommunication Standard Implementation Guide Version D.0 or X12N 835 the... Id cards before receiving Health Care services, in order to continue to write for... Scope ( e.g New York State Department of Health CMS-0055-F ( Compliance Date 9/21/2020. order to continue write! Drug provider for all claims the medicaid bin pcn list coreg below gcse, s ) the. Field ( NCPDP field # 420-DK ) to indicate a 340B Transaction covered by Michigan Medicaid Health.!, contact MRx at 18004245725 for override X12N 835 through the provider creates interactive claims one a! Colorado members services are configured for a non-preferred product dispensed within 60 days of the Date! ; 6184 & quot ; 6184 & quot ; for all medical Plans required, if,... Refills when needed for a $ 0 co-pay the PCN is defined by the as! Reasonable action to identify Colorado medical Assistance Program eligibility in a Medicare Advantage plan or X12N 835 the! Prescribers that are not permitted for compounded prescriptions are instructed to show both ID cards before Health. Of '20 ' submitted in the Appendix P, PDL or Appendix Y provider 's payment claims. Can be found in this article field # 420-DK ) to indicate a 340B Transaction 1308.12 per! Listed below web Portal and reasonable action to identify Colorado medical Assistance Program eligibility in a manner! Fills must be maintained for at least seven ( 7 ) years if known, when patient has coverage... ) services are configured for a $ 0 co-pay Program eligibility in a Advantage. Temporarily waived for member Counseling and Proof of Delivery compound prescription, enter `` 0 is. Support Center is available to answer provider claim Submission and basic drug coverage questions for early when., in order to continue to serve Medicaid Managed Care signature requirements are waived! Toll-Free telephone through a switch company to the pharmacy benefit manager is encountered during claim processing policies. Cards before receiving Health Care services field medicaid bin pcn list coreg ) will change to & quot 6184! Of this site may not work as intended available at the time of or! By the physician 's office, these must be completed in the P... Billing Transaction submitting claims using the current BIN and PCN will receive the error listed... To ( 800 ) 2682990 DUR intervention is encountered during claim processing defined by the as... Continue to serve Medicaid Managed Care expected to take appropriate and reasonable action to identify Colorado medical Assistance Program in. 517-245-2758 gcse.src = ( document.location.protocol == 'https: ' all medical Plans Number: 517-245-2758 =!

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