NCPDP B1 Transaction Billing Request

Transcription

1 Texas Vendor Drug Program Pharmacy Provider Payer Sheet NCPDP B1 Transaction Billing equest Effective Date January 15, 2017 The VDP Pharmacy Provider Payer Sheets are available online at txvendordrug.com/about/policy/payer-sheets. i

2 1 General Information Payer name Texas Vendor Drug Program Traditional edicaid Children with Special Health Care Needs (CSHCN) Services Program Healthy Texas Women (HTW) Program Processor name Conduent (since Jan. 1, 2017) Version/elease D.Ø (since Feb. 1, 2012) Transaction Code / Name B1 / Billing equest Contact/Information Sources Pharmacy Provider Procedure anual txvendordrug.com/about/policy/manual Pharmacy Benefits Access Help Desk Submission Notes Any/all submitted data elements will be edited for valid format and values. Provider software should support any/all data elements on the required segments. eversals will match on: "Service Provider ID" (2Ø1-B1) "Prescription/Service eference Number" (4Ø2-D2) "Product/Service ID" (4Ø7-D7) "Date of Service" (4Ø1-D1) In cases where multiple iterations of a field ( repeating fields ) are allowed, the maximum number of iterations has been indicated. 2

3 3 Field Usage Descriptions andatory () Submitted in accordance with the NCPDP Telecommunication Implementation Guide Version D.Ø. equired () Always submitted. equired When () Submitted under circumstances that are explained in the Comment column. Optional (O) Submitted at the discretion of the pharmacy provider. epeating () Designates a field is repeating. 4 Transaction 4.1 Transaction Header andatory in all cases 1Ø1-A1 BIN Number 61ØØ84 1Ø2-A2 Version/elease Number DØ = Version D.Ø 1Ø3-A3 Transaction Code B1 = Billing Billing equest 1Ø4-A4 Processor Control Number DTXPOD 1Ø9-A9 Transaction Count 1 = One Occurrence 2 = Two Occurrences 3 = Three Occurrences 4 = Four Occurrences Compounds must be transmitted as one transaction. 2Ø2-B2 Service Provider ID Qualifier Ø1 = National Provider Identifier (NPI) 3

4 2Ø1-B1 Service Provider ID 1Ø-digit NPI 4Ø1-D1 Date of Service Fill Date, Format = CCYYDD 11Ø-AK Software Vendor/Certification ID Three-digit software identification number with space fill. 4.2 Insurance andatory 111-A Ø4 = Insurance 3Ø2-C2 Cardholder ID edicaid and HTW cardholder ID numbers begin with 1-6. CSHCN cardholder ID numbers begin with 9. DFPS ID cardholder numbers are 6-8 digits with leading Ø s to total sixteen characters. 4

5 3Ø1-C1 Group ID EDICAID CHIP CSHCN equired by VDP. Enter the name of the payer program. For HTW and DFPS IDs, enter EDICAID Note: B1 transactions for CHIP claims will deny with NCPDP error AF ( Patient Enrolled Under anaged Care"). 4.3 Patient equired 111-A Ø1 = Patient 3Ø4-C4 Date of Birth Format = CCYYDD 3Ø5-C5 Patient Gender Code 1 = ale 2 = Female 311-CB Patient Last Name Submit a comma as the second character if the patient s last name has only 1 character 5

6 4.4 Claim andatory 111-A Ø7 = Claim 455-E Prescription/Service eference Number Qualifier 1 = x Billing 4Ø2-D2 Prescription/Service eference Number Twelve digit prescription number 436-E1 Product/Service ID Qualifier ØØ = Compound Ø3 = National Drug Code (NDC) Value ØØ if Compound Code = 2 4Ø7-D7 Product/Service ID NDC 442-E7 Quantity Dispensed Value Ø if Compound Code = 2 4Ø3-D3 Fill Number Value ØØ used to indicate an original prescription. Values Ø1 through 11 to indicate a refill prescription 4Ø5-D5 Days Supply ay not exceed 185 for edicaid and CSHCN. 4Ø6-D6 Compound Code 1 = Not a Compound 2 = Compound Value 2 for compound claim. 6

7 4Ø8-D8 DAW / Product Selection Code Ø = No Product Selection Indicated 1 = Substitution Not Allowed by Prescriber Value 1 for AC override when physician hand writes Brand Necessary on the face of the prescription. 414-DE Date Prescription Written Format = CCYYDD 415-DF Number of efills Authorized Ø 11 for Nonschedule drugs Ø 5 for Schedule 3, 4, or 5, drugs Ø for Schedule 2 drugs For Nonschedule drug the limit = 11. For Schedule 2 drugs, the limit = Ø For Schedule 3, 4, or 5 drugs or Home Health Supply products, the limit = DJ Prescription Origin Code Ø = Not Known 1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile 5 = Pharmacy. 354-NX Submission Clarification Code Count 1-3 7

8 42Ø-DK Submission Clarification Code 1 = No Override 2 = Other override 8 = Process Compound For Approved Ingredients 2Ø = 34ØB / Disproportionate Share Pricing/Public Health Service 99 = Other Value "2" used when it is medically necessary for the prescribed quantity of a Home Health Supply product to exceed the maximum unit per filling. Value 8 used for compound ingredient override. Value 2Ø used for claims dispensed from 34ØB stock. Value 99 used for overriding Prescriber ID Is Not Covered" (NCPDP 71). 3Ø8-C8 Other Coverage Code Ø = Not Specified By Patient 1 = No Other Coverage 2 = Other Coverage Exists Payment Collected 3 = Other Coverage Billed Claim Not Covered 4 = Other Coverage Exists Payment Not Collected 6ØØ-28 Unit of easure EA = Each G = Grams L = illiliters equired if COB segment is transmitted 461-EU Prior Authorization Type Code edicaid, STA Health and CSHCN: 8 = Payer Defined Exemption equired if Prior Authorization Number Submitted is 8

9 462-EV Prior Authorization Number Submitted edicaid: 8Ø1 = 72-hour emergency override edicaid and CSHCN: 826 = edically accepted indication for vitamins and minerals equired if Prior Authorization Type Code is STA Health Program only: 1Ø27 = Submission of DFPS ID 343-HD Dispensing Status O If submitted, the claim will reject 344-HF Quantity Intended To Be Dispensed O If anything is submitted in this field, the claim will reject 345-HG Days Supply Intended To Be Dispensed O If anything is submitted in this field, the claim will reject 995-E2 oute of Administration 996-G1 Compound Type Ø1 = Anti-Infective Ø2 = Ionotropic Ø3 = Chemotherapy Ø4 = Pain anagement Ø5 = TPN/PPN Ø6 = Hydration Ø7 = Ophthalmic 99 = Other O equired when compound code = Prescriber equired 111-A Ø3 = Prescriber 9

10 466-EZ Prescriber ID Qualifier Ø1 = National Provider Identifier (NPI) 411-DB Prescriber ID 1Ø-digit NPI 427-D Prescriber Last Name O 4.6 Coordination of Benefits/Other Payments Optional 111-A Ø5 = COB/Other Payments 337-4C Coordination of Benefits/Other Payments Count C Other Payer Coverage Type Blank = Not Specified Ø1 = Primary Ø2 = Secondary Ø3 = Tertiary Ø4 = Quaternary Ø5 = Quinary Ø6 = Senary Ø7 = Septenary Ø8 = Octonary Ø9 = Nonary 339-6C Other Payer ID Qualifier edicaid with Private Insurance: Ø3 = Bank Information Number (BIN) If COB segment CSHCN with Private Insurance: 99 = Other edicaid with edicare coverage: 99 = Other 10

11 34Ø-7C Other Payer ID edicaid with Private Insurance: If Other Payer ID Qualifier = Ø3, submit Other Payer s BIN. CSHCN with Private Insurance: If Other Payer ID Qualifier = 99, submit CSHCNTPL edicaid with edicare Part B: If Other Payer ID Qualifier = 99 and Other Payer is edicare Part B, submit EDPATB 443-E8 Other Payer Date If COB segment Format = CCYYDD 341-HB Other Payer Amount Paid Count 1-9 If eject Count not 342-HC Other Payer Amount Paid Qualifier Ø1 = Delivery Ø2 = Shipping Ø3 = Postage Ø4 = Administrative Ø5 = Incentive Ø6 = Cognitive Service Ø7 = Drug Benefit Ø9 = Compound Prep Cost 1Ø = Sales Tax If Other Payer Amount Paid Count is 431-DV Other Payer Amount Paid If Other Payer Amount Paid Qualifier is 11

12 471-5E Other Payer eject Count 472-6E Other Payer eject Code 1 5 If Other Payer Amount Paid Count not If Other Payer eject Count is 4.7 Drug Use eview/professional Pharmacy Service Optional 111-A Ø8 = DU/PPS 473-7E DU Code Counter 1 to 9 If DU segment transmitted 439-E4 eason for Service Code DD = Drug-Drug Interaction HD = High Dose ID = Ingredient Duplication TD = Therapeutic 44Ø-E5 Professional Service Code ØØ = No Intervention Ø =Prescriber consulted PØ = Patient consulted Ø = Pharmacist consulted other source 12

13 441-E6 esult of Service Code 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 4A = Prescribed with acknowledgement 4.8 Pricing andatory 111-A 11 = Pricing 4Ø9-D9 Ingredient Cost Submitted 426-DQ Usual and Customary Charge For claims $10, and over, call VDP. 43Ø-DU Gross Amount Due For claims $10, and over, call VDP. 423-DN Basis of Cost Determination ØØ = Default Ø1 = AWP (Average Wholesale Price) Ø3 = Direct Ø8 = 34ØB / Disproportionate Share Pricing/Public Health Service Ø9 = Other For Service Dates prior to 06/01/2016: Blank or ØØ will default to Direct. For Service Dates after 06/01/2016: The field is no longer used. 13

14 4.9 Compound Optional 111-A 1Ø = Compound 45Ø-EF Compound Dosage Form Description Code 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 17 = Lozenge 18 = Enema 451-EG Compound Dispensing Unit Form Indicator 1 = Each 2 = Grams 3 = illiliters 447-EC Compound Ingredient Component Count E Compound Product ID Qualifier Ø3 = National Drug Code 489-TE Compound Product ID NDC, equired by VDP 448-ED Compound Ingredient Quantity 449-EE Compound Ingredient Drug Cost Optional 14

15 49Ø-UE Compound Ingredient Basis of Cost Determination ØØ = Default Ø1 = AWP (Average Wholesale Price) Ø3 = Direct Ø8 = 34ØB / Disproportionate Share Pricing/Public Health Service Ø9 = Other Optional If Blank or ØØ will default to Direct. 15