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Billing Transaction

By April Ramirez,2014-04-07 21:00
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Billing Transaction

    eFAX Alert

    Log onto www.express-scripts.com for patient

    10-26-05 eligibility, rejection assistance, and more.

Medicare Part D Network Pharmacy:

    Attached is the Express Scripts NCPDP v5.1 Payer Sheet for processing Medicare Part D pharmacy claims. The Payer Sheet also includes processing information for secondary and tertiary claims for Medicare beneficiaries participating in a Medicare Part D plan administered by Express Scripts.

     Important information includes:

    ; ESI Processor Control number for other payer coverage is "SC."

    ; Partial fills are not supported for Medicare beneficiaries with other payer

    coverage.

    ; Additional notes clarify a Medicare beneficiary's other payer coverage

    information, which is sent back to the pharmacy to assist in billing other

    payer coverage.

    ; If you are a provider that serves Long Term Care (LTC) facilities, NCPDP

    3Ø7-C7 Patient Location field has been added to the Patient segment.

    This field must be used to identify Medicare beneficiaries residing in LTC

    or Assisted Living facilities in order to ensure proper payment of these

    claims.

    Please review the payer sheet prior to billing Express Scripts Medicare Part D claims for your Medicare patients enrolled in plans administered by ESI.

    NOTE: Additional plan details will be communicated to you prior to the Medicare Part D implementation date of 1/1/2006.

Thank you!

    Express Scripts Provider Relations Account Team

    Express Scripts, Inc.

    NCPDP Version 5.1

    Medicare Part D Payer Sheet

    Claim transaction segments not depicted within this document may be accepted in the transmission of a claim. However, Express Scripts may not use the information submitted

    to adjudicate claims.

General Information:

Payer Name: Express Scripts, Inc. Date: Oct 2005 Version 1.0

    Plan Name/Group Name: Express Scripts, Inc. - Standard Plan - Exceptions Noted

    Processor: Express Scripts, Inc. Switch:

    Effective: January 01, 2006 Version/Release Number: 5.1

    Contact/Information Source: Provider Relations Account Manager, or

     (800) 824-0898, or

     www.express-scripts.com

    Testing Window: No testing required for Medicare Claim billings and reversals.

    Provider Relations Help Desk Info: (800) 824-0898

    Other versions supported: NCPDP Version 3.2 (Payer sheet available upon request)

    ESI supports a B1 Billing claim transaction and a B2 Reversal claim transaction. Only one Medicare claim may be submitted per transaction to eliminate confusion in the calculation of TrOOP.

    Please see the following pages for additional details regarding the transaction sections of the payer sheet.

    Partial fill Medicare claims are not accepted if beneficiary has other payer coverage. Reject message will display as such: Reject code RK “Partial Fill Transaction not supported.”

    Field Status: M=Mandatory, O=Optional; will be returned when applicable,

     R=Required by ESI to expedite claim processing, "R"=Repeating Field

    2

    Express Scripts, Inc.

    NCPDP Version 5.1

    Medicare Part D Payer Sheet

    Section: Billing Transaction (In Bound)

NOTE: The Transaction Header Segment is the only FIXED length portion of the NCPDP version 5.1 record. All 56

    bytes must accompany the transaction along with the following defined rules:

    ; If numeric - Right justify; zero fill.

    ; If alphanumeric - Left justify; space fill.

Transaction Header Segment - Mandatory in all cases.

    Field # NCPDP Field Name Value Field Status 1Ø1-A1 Bin Number ØØ1884 M

    ØØ2156

    ØØ3592

    ØØ3857

    ØØ3858

    123456

    4ØØØØ4

    61ØØ41

    61ØØ77

    61Ø5Ø2

    61Ø544

    677548

    9ØØØØ2

    1Ø2-A2 Version Release Number 51=Version 5.1 M 1Ø3-A3 Transaction Code B1=Billing M 1Ø4-A4 Processor Control Number* Assigned by ESI* M 1Ø9-A9 Transaction Count 1=One Occurrence M

    2=Two Occurrences

    3=Three Occurrences

    4=Four Occurrences

    2Ø2-B2 Service Provider ID Qualifier Ø5 = Medicaid M

    Ø7 = NCPDP Provider ID

    99=Other

    2Ø1-B1 Service Provider ID Medicaid ID, NCPDP Provider ID, or Other M 4Ø1-D1 Date of Service M 11Ø-AK Software Vendor/Certification ID M

*Please note, if submitting supplemental prescription claims to ESI as a secondary payer the PCN

    must be designated as “SC.”

    Field Status: M=Mandatory, O=Optional; will be returned when applicable,

     R=Required by ESI to expedite claim processing, "R"=Repeating Field

    3

    Express Scripts, Inc.

    NCPDP Version 5.1

    Medicare Part D Payer Sheet

    Patient Segment - Segment is optional, but ESI requires some fields to expedite claim processing. Field # NCPDP Field Name Value Field Status 111-AM Segment Identification Ø1=Patient M 3Ø4-C4 Date of Birth R 3Ø5-C5 Patient Gender Code 1=Male R

    2=Female

    31Ø-CA Patient First Name R 311-CB Patient Last Name R 322-CM Patient Street Address Plan Specific Requirement R 323-CN Patient City Plan Specific Requirement R 324-CO Patient State or Province Plan Specific Requirement R 325-CP Patient Zip/Postal Code Plan Specific Requirement R 3Ø7-C7 Patient Location* Ø=Not specified R

    1=Home

    2=Inter-Care

    3=Nursing Home For LTC Providers

    4=Long Term/Extended Care Only

    5=Rest Home

    6=Boarding Home

    7=Skilled Care Facility

    8=Sub-Acute Care Facility

    9=Acute Care Facility

    1Ø=Outpatient

    11=Hospice

* Field 307-C7 (Patient Location) is a required field to identify where a Medicare beneficiary resides.

    If an LTC facility, please identify by using a value of 3. Use a value of 5 when identifying a

    beneficiary residing in an Assisted Living facility to ensure proper adjudication and payment. There

    are no other values required by ESI at this time.

Insurance Segment - Mandatory

    Field # NCPDP Field Name Value Field Status 111-AM Segment Identification Ø4=Insurance M 3Ø2-C2 Cardholder ID ID assigned to the cardholder. M 312-CC Cardholder First Name Plan Specific Requirement R 313-CD Cardholder Last Name Plan Specific Requirement R 3Ø9-C9 Eligibility Clarification Code Ø=Not Specified R

    1=No Override

    2=Override

    3=Full Time Student

    4=Disabled Dependent

    5=Dependent Parent

    6=Significant Other

    3Ø1-C1 Group ID As appears on card. R 3Ø3-C3 Person Code R

    Field Status: M=Mandatory, O=Optional; will be returned when applicable,

     R=Required by ESI to expedite claim processing, "R"=Repeating Field

    4

    Express Scripts, Inc.

    NCPDP Version 5.1

    Medicare Part D Payer Sheet

    3Ø6-C6 Patient Relationship Code Ø=Not Specified R

    1=Cardholder

    2=Spouse

    3=Child

    4=Other

Claim Segment - Mandatory

    Field # NCPDP Field Name Value Field Status

    111-AM Segment Identification Ø7=Claim M

    455-EM Prescription/Service Reference 1=Rx Billing M

    Number Qualifier

    4Ø2-D2 Prescription/Service Reference M

    Number

    436-E1 Product/Service ID Qualifier Ø1=Universal Product Code (UPC) M

    Ø2=Health Related Item (HRI)

    Ø3=National Drug Code

    99=Other (As Assigned by ESI for Plan Specific

    Requirements)

    4Ø7-D7 Product/Service ID M

    442-E7 Quantity Dispensed R

    4Ø3-D3 Fill Number Ø=Original Dispensing R

    1 to 99 = Refill number

    4Ø5-D5 Days Supply R

    4Ø6-D6 Compound Code 1=Not a Compound R

    2=Compound

    4Ø8-D8 Dispense as Written Ø=No Product Selection Indicated-This is the field R

    (DAW)/Product Selection Code default value that is appropriately used for

    prescriptions where product selection is not an issue.

    Examples include prescriptions written for single

    source brand products and prescriptions written using

    the generic name and a generic product is dispensed.

    1=Substitution Not Allowed by Prescriber-This value

    is used when the prescriber indicates, in a manner

    specified by prevailing law, that the product is to be

    Dispensed As Written.

    2=Substitution Allowed-Patient Requested Product

    Dispensed-This value is used when the prescriber

    has indicated, in a manner specified by prevailing law,

    that generic substitution is permitted and the patient

    requests the brand product. This situation can occur

    when the prescriber writes the prescription using

    either the brand or generic name and the product is

    available from multiple sources.

    3=Substitution Allowed-Pharmacist Selected Product

    Dispensed-This value is used when the prescriber

    has indicated, in a manner specified by prevailing law,

    that generic substitution is permitted and the

    pharmacist determines that the brand product should

    be dispensed. This can occur when the prescriber

    writes the prescription using either the brand or

    Field Status: M=Mandatory, O=Optional; will be returned when applicable,

     R=Required by ESI to expedite claim processing, "R"=Repeating Field

    5

    Express Scripts, Inc.

    NCPDP Version 5.1

    Medicare Part D Payer Sheet

    generic name and the product is available from multiple sources.

    4=Substitution Allowed-Generic Drug Not in Stock-

    This value is used when the prescriber has indicated,

    in a manner specified by prevailing law, that generic substitution is permitted and the brand product is dispensed since a currently marketed generic is not stocked in the pharmacy. This situation exists due to the buying habits of the pharmacist, not because of

    the unavailability of the generic product in the marketplace.

    5=Substitution Allowed-Brand Drug Dispensed as a

    Generic-This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted and the

    pharmacist is utilizing the brand product as the generic entity.

    6=Override-This value is used by various claims

    processors in very specific instances as defined by that claims processor and/or its client(s).

    7=Substitution Not Allowed-Brand Drug Mandated by

    Law-This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted but prevailing law or regulation prohibits the substitution of a brand product even though generic versions of the product may be available in the marketplace.

    8=Substitution Allowed-Generic Drug Not Available in

    Marketplace-This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted and the brand

    product is dispensed since the generic is not currently manufactured, distributed, or is temporarily unavailable.

    9=Other-This value is reserved and currently not in use. NCPDP does not recommend use of this value at the present time. Please contact NCPDP if you intend to use this value and document how it will be utilized by your organization.

    415-DF Number of Refills Authorized Ø=Not Specified R

    1 through 99, with 99 being as needed, refills unlimited

    3Ø8-C8 Other Coverage Code Ø=Not Specified R

    1=No other coverage identified* Requires COB

    2=Other coverage exists-payment collected* segment to be

    3=Other coverage exists-this claim not covered* sent.

    4=Other coverage exists-payment not collected*

    5=Managed care plan denial*

    6=Other coverage denied-not a participating provider*

    Field Status: M=Mandatory, O=Optional; will be returned when applicable,

     R=Required by ESI to expedite claim processing, "R"=Repeating Field

    6

    Express Scripts, Inc.

    NCPDP Version 5.1

    Medicare Part D Payer Sheet

    7=Other coverage exists-not in effect at time of service*

    8=Claim is a billing for a co-pay*

    418-DI Level of Service Ø=Not Specified O

    1=Patient consultation

    2=Home delivery

    3=Emergency

    4=24 hour service

    5=Patient consultation regarding generic product

    selection

    6=In-Home Service

    462-EV ** Prior Auth Number Submitted Submitted when requested by processor. R

    Examples: Prior authorization procedures for

    physician authorized dosage or day supply increases

    for reject 79 'Refill Too Soon'.

    Override Codes:

    98798798798=Dosage Increase

    22222222222=Day Supply Change

**PA will be required for the adjudication of Part B covered drugs submitted under Part D. QLL and

    Step Therapy will be handled “Business as Usual”

    Field Status: M=Mandatory, O=Optional; will be returned when applicable,

     R=Required by ESI to expedite claim processing, "R"=Repeating Field

    7

    Express Scripts, Inc.

    NCPDP Version 5.1

    Medicare Part D Payer Sheet

Prescriber Segment - Required

    Field # NCPDP Field Name Value Field Status 111-AM Segment Identification Ø3=Prescriber M 466-EZ Prescriber ID Qualifier Ø5=Medicaid R

    Ø8=State License

    12=Drug Enforcement Administration (DEA)

    99=Other

    411-DB Prescriber ID R

    COB/Other Payments Segment - Required (See list of clients below who are accepting COB) Field # NCPDP Field Name Value Field Status 111-AM Segment Identification Ø5=COB/Other Payments M 337-4C Coordination of Benefits/Other Value=1 M

    Payments Count

    338-5C Other Payer Coverage Type M 341-HB Other Payer Amount Paid Count Value=1 R 342-HC Other Payer Amount Paid Qualifier Value= Ø8 R 431-DV Other Payer Amount Paid Valid value of $Ø or greater to reflect appropriate R

    Other Payer Amount

The COB segment and all required fields must be sent if the Other Coverage Code (308-C8) field with values = 1-8 is

    submitted in the claim segment.

    Field Status: M=Mandatory, O=Optional; will be returned when applicable,

     R=Required by ESI to expedite claim processing, "R"=Repeating Field

    8

    Express Scripts, Inc.

    NCPDP Version 5.1

    Medicare Part D Payer Sheet

Worker's Compensation Segment Required (See comments below table)

    Field # NCPDP Field Name Value Field Status 111-AM Segment Identification Ø6=Worker's Compensation M 434-DY Date of Injury M 315-CF Employer Name R 316-CG Employer Street Address R 317-CH Employer City Address R 318-CI Employer State/Province Address R 319-CJ Employer Zip/Postal Code R 435-DZ Claim/Reference ID R

Worker’s Compensation Processing Exceptions:

    Submit Metric Decimal Quantity drug claims in V3.2 using the rounding method.

    Submit claims with dollar amounts greater than $9,999.99:

    Claims can be split-billed and the Worker’s Compensation Help Desk can provide override

    support for second claim of split bill,

    OR

    A paper claim can be submitted.

    Partial Fills are not accepted for Worker’s Compensation claims.

DUR/PPS Segment - Required

    Field # NCPDP Field Name Value Field Status 111-AM Segment Identification Ø8=DUR/PPS M 473-7E DUR/PPS Code Counter Value=1 R 439-E4 Reason for Service Code DA=Drug-Allergy R

    DC=Drug-Disease (Inferred)

    DD=Drug-Drug Interaction

    ER=Overuse

    HD=High Dose

    ID=Ingredient Duplication

    LD=Low Dose

    LR=Underuse

    MX=Excessive Duration

    ND=New Disease/Diagnosis

    PA=Drug-Age

    PG=Drug-Pregnancy

    PS=Product Selection Opportunity

    SX=Drug-Gender

    TD=Therapeutic

    Field Status: M=Mandatory, O=Optional; will be returned when applicable,

     R=Required by ESI to expedite claim processing, "R"=Repeating Field

    9

    Express Scripts, Inc.

    NCPDP Version 5.1

    Medicare Part D Payer Sheet

    44Ø-E5 Professional Service Code ØØ=No intervention R

    AS=Patient assessment

    CC=Coordination of care

    DE=Dosing evaluation/determination FE=Formulary enforcement

    GP=Generic product selection MA=Medication administration MØ=Prescriber consulted

    MR=Medication review

    PE=Patient education/instruction PH=Patient medication history PM=Patient monitoring

    PØ=Patient consulted

    PT=Perform laboratory test

    RØ=Pharmacist consulted other source RT=Recommend laboratory test SC=Self-care consultation

    SW=Literature search/review

    TC=Payer/processor consulted TH=Therapeutic product interchange

    441-E6 Result of Service Code ØØ=Not Specified R

    1A=Filled As Is, False Positive 1B=Filled Prescription As Is

    1C=Filled, With Different Dose 1D=Filled, With Different Directions 1E=Filled, With Different Drug 1F=Filled, With Different Quantity 1G=Filled, With Prescriber Approval 1H=Brand-to-Generic Change 1J=Rx-to-OTC Change

    1K=Filled with Different Dosage Form 2A=Prescription Not Filled

    2B=Not Filled, Directions Clarified 3A=Recommendation Accepted 3B=Recommendation Not Accepted 3C=Discontinued Drug

    3D=Regimen Changed

    3E=Therapy Changed

    3F=Therapy Changed-cost increased acknowledged

    3G=Drug Therapy Unchanged 3H=Follow-Up/Report

    3J=Patient Referral

    3K=Instructions Understood

    3M=Compliance Aid Provided 3N=Medication Administered

    474-8E DUR/PPS Level of Effort Ø=Not Specified R

    11=Level 1 (Lowest)

    12=Level 2

    13=Level 3

    14=Level 4

    15=Level 5 (Highest)

    Field Status: M=Mandatory, O=Optional; will be returned when applicable,

     R=Required by ESI to expedite claim processing, "R"=Repeating Field

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