PAYER HEET Table of Contents Highlights. 2 General Information... 3 Billing Transaction/egments and Fields 3 Reversal Transaction. 7 Paid (or Duplicate of Paid) Response. 8 Reject Response 11 Appendices Appendix A edicare Part D ubmission Requirements 13 Appendix B Cognitive ervices 15 1
PAYER HEET Highlights Updates, Changes & Reminders - February 2007 The following is a summary of our new requirements. The items highlighted in the payer sheet illustrate the new processing rules. National Provider Identifier (NPI) information tate of D ProDUR BIN Change Cognitive ervices ingle Transaction COB Patient Location Code ubmission edicare Part B vs. edicare Part D; A5/A6 response messaging Please carefully review the payer sheet below since the submission of certain optional data elements in NCPDP Version 5.1 is required by Caremark Plan ponsors and must be submitted for processing. 2
PAYER HEET PART 1: GENERAL INFORATION Payer/Processor Name: Caremark Revised Date: February 2007 Plan Name/Group Name: All Effective as of: February 2007 (For BIN Version/Release #: 5.1 610084 & NPI; the exact date in February is listed by the data element) Contact/Information ource: Caremark Retail ervices/director, Industry tandards, ystems & Practices networksys@caremark.com Pharmacy Help Desk Information Inquiries can be directed to the interactive voice response (IVR) system or the Pharmacy Help Desk. [24 hours a day) The Pharmacy Help Desk numbers are provided below: ystem RXBIN Help Desk Legacy ADV 004336 1-800-364-6331 Legacy PC 610415 1-800-345-5413 Legacy CRK 610029 1-800-421-2342 PART 2: BILLING TRANACTION / EGENT AND FIELD The following lists the segments available in a Billing Transaction. The document also lists values as defined under Version 5.1. The Transaction Header egment is mandatory. The segment summaries included below list the mandatory data fields. =andatory as defined by NCPDP =ituational as defined by Plan R=Required as defined by the Processor Transaction Header egment: andatory 1Ø1-A1 BIN Number 610415, 004336, 610029, 012114, 610084 BIN 012114 is used for claims processed under plans that are supplemental to edicare or when edicare is paying as a supplemental plan. BIN 610084 (Effective 2/04/07) is used for health plans that participate in the tate of D ProDUR program. These prescriptions are transmitted to AC, Inc. and are routed to Caremark. 1Ø2-A2 Version/Release Number 51 NCPDP v5.1 1Ø3-A3 Transaction Code B1 Billing Transaction 3
1Ø4-A4 Processor Control Number Default PCNs by BIN: 610415: PC 004336: ADV or as communicated or printed on card. 610029: CRKblankblank or RXGRP printed on card. PAYER HEET Other PCNs may be required as communicated or printed on card. For BIN 610029, if set to CRKblankblank, the RXGRP must be submitted as printed on the card. Default edicare Part D COB PCNs to be submitted with BIN 012114: COBPC COBADV COBCRK COBEGPC COBEGADV COBEGCRK Other edicare Part D COB PCNs may be required as communicated or printed on card. 1Ø9-A9 Transaction Count 1, 2, 3, 4 RxBINs 610415 & 004336 accepts up to four billing transactions (B1) per transmission Only 1 transaction is permitted for edicare Part D and COB Billing. 2Ø2-B2 ervice Provider ID Qualifier 01, 05, 07, 08 RXBIN 610415 & 004336 accept qualifiers 01 (effective 2/26/07), 05, 07 & 08 RXBIN 610029 accepts qualifier 01 (effective 2/26/07) & 07 NPI effective 2/26/07 2Ø1-B1 ervice Provider ID NPI or NCPDP Provider ID Number 4Ø1-D1 Date of ervice CCYYDD 11Ø-AK oftware Vendor/Certification ID The oftware Vendor/Certification ID is the same for all RxBINs Patient egment: Required Field NCPDP Field Name Value Comment 111-A egment Identification Ø1 Patient egment 304-C4 Date of Birth R CCYYDD 305-C5 Patient Gender Code R 310-CA Patient First Name R Required for all RxBINs 311-CB Patient Last Name R Required for all RxBINs 322-C Patient treet Address Required for some federal programs 323-CN Patient City Address Required for some federal programs 324-CO Patient tate/province Required for some federal programs Address 325-CP Patient Zip/Postal Zone Required for some federal programs 307-C7 Patient Location Required for Home Infusion & Long Term Care billing 4
PAYER HEET Insurance egment: andatory 111-A egment Identification Ø4 Insurance egment 3Ø2-C2 Cardholder ID 301-C1 Group ID R As printed on the ID card 303-C3 Person Code R As printed on the ID card 306-C6 Patient Relationship Code R Claim egment: andatory 111-A egment Identification Ø7 Claim egment 455-E Prescription/ervice Reference Number Qualifier 1= Rx Billing 2 = ervice Billing 4Ø2-D2 Prescription/ervice Reference Number 436-E1 Product/ervice ID Qualifier 03 06 07 ervice billing supported on RxBIN 610029 only as defined in the Appendix Rx Number for Rx/ervice Billing NDC Number Qualifier DUR/PP Qualifier supported for RxBIN 610029 only CPT4 Qualifier supported for RxBIN 610029 only 4Ø7-D7 Product/ervice ID NDC Number CPT 4 value of 0115T supported for RxBIN 610029 only 442-E7 Quantity Dispensed R 403-D3 Fill Number R 405-D5 Days upply R 406-D6 Compound Code R 408-D8 DAW / Product election Code R 414-DE Date Prescription Written R CCYYDD, Required for all RxBINs 415-DF Number of Refills Authorized R 461-EU Prior Authorization Type Code Required for pecific Overrides 462-EV Prior Authorization Number ubmitted 308-C8 Other Coverage Code 2, 3, 4, 5, 6, 7, 8 R Required for pecific Overrides For COB egment Billing: Use value 2 when previous payer paid the claim Use values 3 7 when payment was not collected from the previous payer For Copay Only Billing: Use values 3-7 when payment was not collected from the previous payer Use value 8 when previous payer paid the claim 5
PAYER HEET Claim egment: andatory (These fields applicable to RxBIN 610029 only) 343-HD Dispensing tatus P=Partial Fill C=Partial Fill Completion Required for Partial Fills ust Be P or C for partial fills Partial Fills will not be accepted for 456-EN 457-EP Associated Prescription/ervice Reference Number Associated Prescription/ervice Date 403-D3 Fill Number 0=Original Fill 1 to 99=Refill Number COB Billing Required for Partial Fill Completion Rx Number of Associated Partial Fill Transaction Required for Partial Fill Completion Fill Date of Associated Partial Fill Transaction Required for Partial Fills 344-HF Quantity Intended To Be Dispensed Required for Partial Fills 345- Days upply Intended To Be Required for Partial Fills HG Dispensed Prescriber egment: Required 111-A egment Identification Ø3 Prescriber egment 466-EZ Prescriber ID Qualifier R 01 = NPI (effective 2/26/07) 12=DEA Number 99=Other 411-DB Prescriber ID R COB/Other Payments egment: Optional 111-A egment Identification 05 COB/Other Payments egment 337-4C Coordination of Benefits/Other Up to 3 occurrences Payments Count 338-5C Other Payer Coverage Type 01 = Primary, 02 = econdary, 03 = Tertiary, 99 = Composite 339-6C Other Payer ID Qualifier R 03 = BIN 340-7C Other Payer ID R 443-E8 Other Payer Date R 341-HB Other Payer Amount Paid Count Required if other payer(s) paid 342-HC Other Payer Amount Paid Qualifier 07= Drug Benefit, 08 = um of all Reimbursement 431-DV Other Payer Amount Paid Required if other payer(s) paid 471-5E Other Payer Reject Count Required if other payer rejected 472-6E Other Payer Reject Code Required if other payer rejected 6
PAYER HEET DUR/PP egment: Optional 111-A egment Identification Ø8 DUR/PP egment 473-7E DUR / PP Code Counter 1-9 Occurrences ubmitted when requested by processor 439-E4 Reason for ervice Code ubmitted when requested by processor 440-E5 Professional ervice Code ubmitted when requested by processor 441-E6 Result of ervice Code ubmitted when requested by processor Pricing egment: andatory 111-A egment Identification 11 Pricing egment 409-D9 Ingredient Cost ubmitted R 412-DC Dispensing Fee ubmitted R 430-DU Gross Amount Due R Required for RxBIN 610029 only 423-DN Basis Of Cost Determination R Required for RxBIN 610029 only 433-DX Patient Paid Amount ubmitted R Required for RxBIN 610029 only 478-H7 Other Amount Claimed ubmitted Count R Required for Coordination of Benefits (COB) Copay only billing 479-H8 Other Amount Claim ubmitted Qualifier R Required for Coordination of Benefits (COB) Copay only billing 48 - H9 Other Amount Claimed ubmitted R Required for Coordination of Benefits (COB) Copay only billing 481-HA Flat ales Tax Amount ubmitted R When required by state law 426- Usual and Customary Charge R Required for all RxBINs DQ 482-GE Percentage ales Tax Amount R When required by state law ubmitted 483-HE Percentage ales Tax Rate R When required by state law ubmitted 484-JE Percentage ales Tax Basis ubmitted R Required when submitting Percentage ales Tax Amount ubmitted and Percentage ales Tax Rate ubmitted. Clinical egment: Optional** (RxBIN 610029 only) **Diagnosis Code is required when the participant and the drug is covered by edicare. 111-A egment Identification 13 Clinical egment 491-VE Diagnosis Code Count 1-9 R 492- Diagnosis Code Qualifier 01 R ICD9 WE 424- DO Diagnosis Code R 7
PAYER HEET PART 3: REVERAL TRANACTION Transaction Header egment: andatory 1Ø1-A1 BIN Number 610415, 004336, 610029, 610084, 012114 1Ø2-A2 Version/Release Number 51 1Ø3-A3 Transaction Code B2 104-A4 Processor Control Number Default PCNs by BIN: 610415: PC 004336: ADV or as communicated or printed on card. 610029: CRKblankblank or RXGRP printed on card. Other PCNs may be required as communicated or printed on card. For BIN 610029, if set to CRK, the RXGRP must be submitted as printed on the card. Default edicare Part D COB PCNs to be submitted with BIN 012114: COBPC (Legacy PC) COBADV Legacy Advance Paradigm) COBCRK (Legacy Caremark) 1Ø9-A9 Transaction Count 01=For RxBIN 610029 One reversal (B2) per transmission for RxBIN 610029 01-04 = For RxBIN610415 & RxBIN004336 2Ø2-B2 ervice Provider ID Qualifier 07 2Ø1-B1 ervice Provider ID NPI or NCPDP Provider ID Number Up to 4 reversals (B2) per transmission for RxBIN 610415 & RxBIN 004336. NPI effective 2/26/2007 4Ø1-D1 Date of ervice CCYYDD 11Ø-AK oftware Vendor/Certification ID The oftware Vendor/Certification ID is the same for all RxBINs 8
PAYER HEET Claim egment: andatory 111-A egment Identification Ø7 Claim egment 455-E Prescription/ervice Reference 1=Rx Billing ervice billing not supported Number Qualifier 4Ø2- Prescription/ervice Reference Rx Number D2 Number 436-E1 Product/ervice ID Qualifier 03=NDC ID 4Ø7- Product/ervice ID NDC Number D7 343-HD Dispensing tatus P=Partial Fill C=Partial Fill Completion RxBIN 610029 Only. Required for partial fills ust be P or C for partial fills Insurance egment: andatory 111-A egment Identification Ø4 Insurance egment 3Ø2-C2 Cardholder ID 301-C1 Group ID R As printed on the ID card PART 4: PAID (OR DUPLICATE OF PAID) REPONE Transaction Header egment: andatory 1Ø2-A2 Version/Release Number ame value as in NCPDP v5.1 51 1Ø3-A3 Transaction Code ame value as in Billing Transaction B1 1Ø9-A9 Transaction Count ame value as in 1-4 1-4 occurrences supported for B1 transaction 5Ø1-F1 Header Response tatus A 2Ø2-B2 ervice Provider ID ame value as in Qualifier 07=NCPDP Provider ID 2Ø1-B1 ervice Provider ID ame value as in NCPDP Provider ID Number 4Ø1-D1 Date of ervice ame value as in CCYYDD Response Insurance egment: Optional 111-A egment Identification 25 Response Insurance egment 524-FO Plan ID 568-J7 Payer ID Qualifier 99 99 = Other 569-J8 Payer ID Response essage egment: Optional 111-A egment Identification 20 Response essage egment 504-F4 essage R 9
PAYER HEET Response tatus egment: andatory 111-A egment Identification 21 Response tatus egment 112-AN Transaction Response P=Paid tatus D=Duplicate of Paid 503-F3 Authorization Number R 526-FQ Additional essage Information R Response Claim egment: andatory 111-A egment Identification 22 Response Claim egment 455-E Prescription/ervice 1=Rx Billing ervice Billing not supported Reference Number Qualifier 4Ø2-D2 Prescription/ervice Reference Number Rx Number Response Pricing egment: andatory 111-A egment Identification 23 Response Pricing egment 505-F5 Patient Pay Amount R This data element will be returned on all paid claims. Please read this data element to assist in COB billing. 506-F6 Ingredient Cost Paid 507-F7 Dispensing Fee Paid 509-F9 Total Amount Paid R This data element will be returned on all paid claims. Please read this data element to assist in COB billing. 512-FC Accumulated Deductible Amount 513-FD Remaining Deductible Amount 514-FE Remaining Benefit Amount 517-FH Amount Applied to Periodic Deductible 518-FI Amount Copay / Coinsurance 519-FJ Amount Attributed to Product election 520-FK Amount Exceeding Periodic Benefit aximum 521-FL Incentive Amount Paid 522-F Basis of Reimbursement Determination 523-FN Amount Attributed ales Tax 10
558-AW 559-AX 560-AY Flat ales Tax Amount Paid Percentage ales Tax Amount Paid Percentage ales Tax Rate Paid PAYER HEET Tax dollar amount paid to pharmacy Rate used to calculate Percentage ales Amount Paid 561-AZ Percentage ales Tax Basis Paid Code indicating basis of dollars used in calculating tax in the final paid claim 562-J1 Professional ervice Fee Paid 563-J2 Other Amount Paid Count This data element will only be returned in COB Copay only billing 564-J3 Other Amount Paid Qualifier 99 = Other This data element will only be returned in COB Copay only billing 565-J4 Other Amount Paid This data element will only be returned in COB Copay only billing 566-J5 Other Payer Amount Paid Recognized 557-AV Tax Exempt Indicator This indicator, a value of 1, identifies those plans that are exempt from sales tax. 346-HH 347-HJ 348-HK 349-H Basis Of Calculation Dispensing Fee Basis Of Calculation Copay Basis Of Calculation Flat ales Tax Basis Of Calculation Percentage of ales Tax Response DUR/PP egment: Optional 111-A egment Identification 24 Response DUR/PP egment 567-J6 DUR / PP Response Code Counter 439-E4 Reason for ervice Code 528-F Clinical ignificance Code 529-FT Other Pharmacy Indicator 530-FU Previous Date of Fill 531-FV Quantity of Previous Fill 532-FW Database Indicator 533-FX Other Prescriber Indicator 544-FY DUR Free Text essage PART 5: Reject Response Transaction Header egment: andatory 1Ø2-A2 Version/Release Number ame value as in 51 NCPDP v5.1 11
1Ø3-A3 Transaction Code ame value as in B1 1Ø9-A9 Transaction Count ame value as in 01 04 5Ø1-F1 Header Response tatus A 2Ø2-B2 ervice Provider ID Qualifier ame value as in 07=NCPDP Provider ID 2Ø1-B1 ervice Provider ID ame value as in NCPDP Provider ID Number 4Ø1-D1 Date of ervice ame value as in PAYER HEET Billing Transaction 1 4 occurrences supported for B1 transaction CCYYDD Response essage egment: Optional Field NCPDP Field Name Value Comment 111-A egment Identification 20 Response essage egment 504-F4 essage R Response Insurance egment: Optional Field NCPDP Field Name Value Comment 111-A egment Identification 25 Response Insurance egment 301-C1 Group ID 524-FO Plan ID Response tatus egment: andatory Field NCPDP Field Name Value Comment 111-A egment Identification 21 Response tatus egment 112-AN Transaction Response R = Reject tatus 503-F3 Authorization Number 510-FA Reject Count R 511-FB Reject Code R 526-FQ Additional essage Information Response Claim egment: andatory Field NCPDP Field Name Value Comment 111-A egment Identification 22 Response Claim egment 455-E Prescription/ervice 1=Rx Billing ervice billing not supported Reference Number Qualifier 402-D2 Prescription/ervice Reference Number Rx Number 12
PAYER HEET Response DUR/PP egment: Optional 111-A egment Identification 24 Response DUR/PP egment 567-J6 DUR / PP Response Code Counter 439-E4 Reason for ervice Code 529-FT Other Pharmacy Indicator 530-FU Previous Date of Fill 531-FV Quantity of Previous Fill 532-FW Database Indicator 533-FX Other Prescriber Indicator 544-FY DUR Free Text essage 528-F Clinical ignificance Code 13
PAYER HEET Appendix A: edicare Part D ubmission Requirements General edicare Part D ubmission Requirements for Coordination of Benefits For all other primary edicare Part D plan sponsors that have not implemented single transaction coordination of benefits (T COB), the following coordination of benefits information is essential when submitting claims for edicare Part D beneficiaries: If edicare Part D is the primary coverage, the standard RXBIN/RXPCN combinations should be used (refer to the Caremark plan sponsor grid distributed on 12/23/2006) For supplemental coverage after the primary edicare Part D claim is processed, or if edicare Part D falls into a secondary/supplemental status due to other existing primary coverage (commercial coverage, workers comp, etc.), please use the following RXBIN/RXPCN combinations: RXBIN Processor Control Number (PCN) Other Coverage Code COBPC 08 COBADV 08 012114 COBCRK 08 COBEGADV 02 COBEGCRK 02 Note: Claims submitted under RXBIN 012114 must be routed through the pharmacy s switch to the TrOOP Facilitator (Per e) do not use lines that are directly connected to Caremark.[ Caremark will respond back to the pharmacy in the message text fields indicating any other coverage that may apply to edicare Part D members. Please ensure that pharmacy employees can easily read this information so that supplemental claims can be submitted according to the message instructions. ingle Transaction Coordination of Benefits (T COB) Caremark has developed a ingle Transaction Coordination of Benefits (T COB) process where the pharmacy provider sends one transaction to Caremark and, the claim adjudicates against both primary and secondary plans before returning one final response to the pharmacy provider. This type of COB is for certain edicare Part D Plan ponsors whose plan design resides on RXBIN 004336, and whose benefit is comprised of a group of beneficiaries that are both primary and secondary within this edicare Part D plan. Please refer to the pharmacy notification distributed via fax and/or email on 12/23/2006 for more information. 14
PAYER HEET Patient Location Codes To ensure proper reimbursement, it is important that your pharmacy submit accurate patient location codes. Patient location codes must be entered in field 307-C7 (Patient Location) for every claim submission in order for appropriate adjudication and payment. As recommended by The National Council for Prescription Drug Programs (NCPDP), Caremark will accept the following values: Patient Location (NCPDP Data Element 307-C7) NCPDP Definition Caremark Claim Type 0 as a default Not specified Retail claims 1 Home Home infusion claims 3 Nursing Home Qualified LTC claims Note: Home infusion and long-term care claims must meet the C qualifications (i.e., skilled nursing unit, etc.) in order to submit these patient location codes and receive appropriate payment. Reject essaging for Part B versus Part D Drug Coverage Determinations In order to comply with C guidance encouraging adoption of a new standardized procedure using structured reject "coding" in the message field, Caremark implemented this standardization, effective July 2006. This guidance and outcome resulted from retail pharmacists needing more specific reject messages in order to assist edicare beneficiaries. This process has been approved by the National Council for Prescription Drug Programs (NCPDP) for two specific messages addressing rejections for (1) drugs excluded from Part D coverage as mandated by the edicare odernization Act; and (2) drugs that are covered under edicare Part B for the designated edicare beneficiary. The codes below are returned to your pharmacy system in the free text message fields per the NCPDP standard. The codes cannot be used in the reject code field until a new claim standard is named through C guidance. Your software must interpret these codes from the free text message field so that the proper messages are displayed. Reject Code A 5 A 6 Description Not covered under Part D Law This medication may be covered under Part B and therefore cannot be covered under the Part D basic benefit for this beneficiary 15
PAYER HEET Appendix B: Billing Requirements for Cognitive ervices Program for RXBIN 610029 Only A Pharmacist can provide cognitive services face-to-face with a patient. The pharmacy can bill for these professional services via current procedural terminology (CPT) codes. The cognitive services plan sponsor allows specific pharmacies to conduct brown bag consults by a pharmacist once a year for $30.00. The patient brings all medications (prescription, OTC, vitamins and/or supplements in a brown bag to the pharmacy, and the pharmacist provides consultative services regarding the patient s drug utilization. The pharmacy bills according to the information below. Processing Cognitive ervices Claims: RXBIN 610029 ONLY Qualifying RXBIN PCN RXGRP Other Data Elements Required Cognitive ervices are only reimbursed once per member per calendar year. 610029 CRK DFHC, DFFH First Health ELECT Plan participants only. Prescription/ervice Reference Number Qualifier (455-E) 02 New Prescription/ervice Reference Number (402-D2) Product/ervice ID Qualifier (436-E1) 07 Product/ervice ID (407-D7) 0115T Days upply 1- This communication and any attachments may contain confidential information. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution, or copying of it or its contents, is prohibited. If you have received this communication in error, please notify the sender immediately by telephone and destroy all copies of this communication and any attachments. This communication is a Caremark Document within the meaning of the Provider anual. 16