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Compound Drug Pharmacy Claim Form (30-4) Completion (compound comp)

By Henry Carter,2014-04-13 21:44
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Compound Drug Pharmacy Claim Form (30-4) Completion (compound comp)

Compound Drug Pharmacy compound comp

    Claim Form (30-4) Completion 1

    The Compound Drug Pharmacy Claim Form (30-4) is used by pharmacies to bill Medi-Cal for multiple ingredient compound drug prescriptions and single ingredient sterile transfers. Ingredients that do not

    have an associated National Drug Code (NDC) must be billed using the 30-4 claim form and include an attached catalog page, invoice or other supporting documentation reflecting pricing information for the ingredients.

    Providers may submit compound drug claims online through the Point of Service (POS) network using the National Council for Prescription Drug Programs (NCPDP), Version 5.1 standard and the pharmacy’s software. Claims submitted online will be immediately adjudicated, giving the provider immediate feedback that the claim has paid, and the amount paid; or, if the claim is denied, what problems must be corrected to allow payment. There is currently no batch Computer Media Claims (CMC) submission method for compound pharmacy claims.

    Providers can access the POS network using vendor-supplied hardware and software. Compound pharmacy claims submission is not currently allowed on the POS device available through the Department of Health Care Services (DHCS) Fiscal Intermediary (FI). For more information, call the Telephone Service Center (TSC) at 1-800-541-5555.

    Pharmacy providers with Internet access also may submit compound pharmacy claims using the Real-Time Internet Pharmacy (RTIP) claim submission system on the Medi-Cal Web site (www.medi-cal.ca.gov). RTIP claim transactions require a completed Medi-Cal Point of Service (POS)

    Network/Internet Agreement. Providers can request an agreement from TSC at 1-800-541-5555.

    Completed agreements should be sent to the following location:

     Attn: POS/Internet Help Desk

     ACS

     820 Stillwater Road

    West Sacramento, CA 95605

RTIP submitters for compound pharmacy claims also must complete the Medi-Cal Telecommunications

    Provider and Biller Application/Agreement and send to the following address:

     Attn: CMC Unit

     ACS

     P.O. Box 15508

     Sacramento, CA 95852-1508

    Crossover compound pharmacy claims that do not cross over automatically via NCPDP must be billed on the Compound Drug Pharmacy Claim Form (30-4). These claims cannot be billed via CMC, POS, or

    RTIP. For more information and billing examples, refer to the Medicare/Medi-Cal Crossover Claims:

    Pharmacy Services Billing Examples section of this manual.

Non-compound pharmacy claims must be billed using the Pharmacy Claim Form (30-1). For more

    information, refer to the Pharmacy Claim Form (30-1) Completion section of this manual. Durable

    Medical Equipment (DME) and blood products must be billed using the CMS-1500 claim form. For more

    information, refer to the CMS-1500 Completion section of this manual.

2 Compound Drug Pharmacy Claim Form (30-4) Completion Pharmacy 767 January 2012

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    Figure 1. Medi-Cal Required Fields (Sample Compound Drug Pharmacy Claim Form [30-4]).

    2 Compound Drug Pharmacy Claim Form (30-4) Completion Pharmacy 657 June 2007

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    Explanation of Form Items The following item numbers and descriptions correspond to the

     sample Compound Drug Pharmacy Claim Form (30-4) on the previous

    page. All items must be completed unless otherwise noted in these

    instructions.

     For general paper claim billing instructions, refer to the Forms:

    Legibility and Completion Standards section of this manual.

     Item Description

     1. CLAIM CONTROL NUMBER. For the DHCS FI use only. Do

     not mark in this area. A unique 13-digit number, assigned by

     the FI to track each claim, will be entered here when the claim

     is received by the FI.

     2. ID QUALIFIER. Identifies the NCPDP 5.1 standard provider

    ID type. Enter 05 to indicate a Medi-Cal Pharmacy Provider

    ID.

    3. PROVIDER ID. Enter the National Provider identifier (NPI).

    Do not submit claims using a Medicare provider number,

    State license number or NCPDP number.

2 Compound Drug Pharmacy Claim Form (30-4) Completion Pharmacy 717 December 2009

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     Item Description

     3a. PROVIDER NAME, ADDRESS, PHONE NUMBER. Enter the

    provider name, address and telephone number if this

    information is not pre-imprinted on the claim form. Confirm

    this information is correct before submitting the claim form.

     4. ZIP CODE. Enter the provider’s nine-digit ZIP code if this

     information is not already pre-imprinted on the claim form.

     Note: The nine-digit ZIP code entered in this box must match

    the billing provider’s nine-digit ZIP code on file for

    claims to be reimbursed correctly.

2 Compound Drug Pharmacy Claim Form (30-4) Completion Pharmacy 675 March 2008

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    Item Description

     5. PATIENT NAME. Enter the patient’s last name, first name

    and middle initial, if known. Avoid nicknames or aliases.

    Newborn Infant When submitting a claim for a newborn infant using the

     mother’s ID number, enter the infant’s name, sex and year of

     birth in the appropriate spaces. Enter the complete date of

     birth in (MMDDYYYY) format where “MM” is the two-digit

     month, “DD” is the two-digit day, and “YYYY” is the four-digit

     year and write “Newborn infant using mother’s card” in the

     Specific Details/Remarks area of the claim.

     If the infant has not yet been named, write the mother’s last

    name followed by “Baby Boy” or “Baby Girl” (example: Jones,

    Baby Girl). If newborn infants from a multiple birth are being

    billed in addition to the mother, each newborn must also be

    designated by number or letter (example: Jones, Baby Girl,

    Twin A).

     Services to an infant may be billed with the mother’s ID for the

    month of birth and the following month only. After this time,

    the infant must have his or her own Medi-Cal ID number.

    6. MEDI-CAL IDENTIFICATION NUMBER. Enter the

    14-character recipient ID number as it appears on the

    Benefits Identification Card (BIC).

     7. SEX. Use the capital letter “M” for male or “F” for female.

    Obtain the sex indicator from the BIC. (For newborns, see

    Item 5.)

2 Compound Drug Pharmacy Claim Form (30-4) Completion Pharmacy 612 August 2005

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     Item Description

8. DATE OF BIRTH. Obtain this number from the recipient’s

    BIC. Enter the date in MMDDYYYY format, where “MM” is the

    two-digit month, “DD” is the two-digit day and “YYYY” is the

    four-digit year. For example, a birth date of March 8, 2005

    should be entered as “03082005.” Birth dates may not be in

    the future. This information must be entered to successfully

    process the claim.

9. DATE OF ISSUE. Obtain this number from the recipient’s

    BIC. Enter the date in MMDDYYYY format, where “MM” is

    the two-digit month, “DD” is the two-digit day and “YYYY” is

    the four-digit year. For example, an issue date of

    March 8, 2005 should be entered as “03082005.”

    10. PRESCRIPTION NUMBER. Enter the prescription number in

    this space for reference on the Remittance Advice Details

    (RAD). A maximum of eight digits may be used.

    11. DATE OF SERVICE. Enter the date that the prescription was

    filled in eight-digit MMDDYYYY format where “MM” is the

    two-digit month, “DD” is the two-digit day and “YYYY” is the

    four-digit year (for example, March 8, 2005 should be entered

    as 03082005). Compound pharmacy claims are only

    accepted on the 30-4 form for dates of service on or after

    September 22, 2003.

    12. TOTAL METRIC QUANTITY. Enter the quantity of the entire

    amount dispensed and being billed on this claim. Quantities

    must be in metric decimal format. Do not include a decimal in

    either of the two fields that make up the metric decimal

    quantity or the claim will be returned. Do not include

    measurement descriptors such as “Gm” or “cc”.

    For example: A 2.5 Gm powder will be 2 in the Whole Units

    box and 5 in the Decimal box and three 2.5 cc ampules will

    be 2.5 x 3 = 7.5 (7 in the Whole Units box and 5 in the

    Decimal box).

    2 Compound Drug Pharmacy Claim Form (30-4) Completion Pharmacy 612 August 2005

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     Item Description

13. CODE I (RESTRICTIONS) MET? Optional item. A “Y”

    indicates the Code I restriction for the drug was met. Refer to

    the Contract Drugs List sections in this manual for more

    information.

    14. DAY SUPPLY. Enter the estimated number of days that the

    drug dispensed will last.

    15. PATIENT LOCATION. Optional item. If the recipient is

    residing in a Nursing Facility (NF) Level A or B or Nursing

    Facility (NF) Level B (Adult Subacute), enter the appropriate

    code.

     Code Description

     C Nursing Facility (NF) Level A

     4 Nursing Facility (NF) Level B

     F Nursing Facility (NF) Level B (Adult Subacute)

     F Subacute Care Facility

     G Intermediate Care FacilityDevelopmentally

    Disabled (NF-A/DD)

     H Intermediate Care FacilityDevelopmentally

    Disabled, Habilitative (NF-A/DD-H)

     I Intermediate Care FacilityDevelopmentally

    Disabled, Nursing (NF-A/DD-N)

     M Nursing Facility Level B (Pediatric Subacute) Field left blank Not Specified *

    * If the recipient is not residing in any of these

    facilities, leave Item 15 blank.

    16. MEDICARE STATUS. Medicare status codes are required for

    Charpentier claims. In all other circumstances, these codes

    are optional. The Medicare status codes are:

     Code Explanation

     R Medi/Medi Charpentier: Rates

     L Medi/Medi Charpentier: Benefit Limits

     T Medi/Medi Charpentier: Both Rates and

    Benefit Limitations

     0 Under 65, does not have Medicare coverage Field left blank Not Specified *

    * If the recipient is not residing in any of these facilities,

    leave Item 15 blank.

    2 Compound Drug Pharmacy Claim Form (30-4) Completion Pharmacy 602 March 2005

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     Item Description

    17. ID QUALIFIER. Identifies the type of prescriber ID submitted

    (State license number, Drug Enforcement Administration

    [DEA] number, etc). Medi-Cal currently accepts only a

    provider’s State license number. Enter 08 to indicate a State

    license number under NCPDP 5.1 standards.

    18. PRESCRIBER ID. Enter the State license number of the

    prescriber or, if applicable, the license number of the certified

    nurse-midwife, the nurse practitioner, the physician assistant,

    the naturopathic doctor, or the pharmacist who function

    pursuant to a policy, procedure, or protocol as required by

    Business and Professions Code statutes. Do not use the Drug

    Enforcement Administration Narcotic Registry Number. This

    information must be entered for your claim to successfully

    process.

19. PRIMARY ICD-CM. Optional item. If available, enter all

    letters and/or numbers of the International Classification of thDiseases 9 Revision Clinical Modification (ICD-9-CM)

    code for the primary diagnosis, including the fourth and fifth

    digits, if present. Do not enter the decimal point.

20. SECONDARY ICD-CM. Optional item. See “Primary

    ICD-CM” for description.

21. DOSAGE FORM DESCRIPTION CODE. Enter the

    appropriate code to indicate the dosage form of the finished

    compound.

    Code Description

    01 Capsule

    02 Ointment

    03 Cream

    04 Suppository

    05 Powder

    06 Emulsion

    07 Liquid

    10 Tablet

    11 Solution

    12 Suspension

    13 Lotion

    14 Shampoo

    15 Elixir

    16 Syrup

    17 Lozenge

    18 Enema

    Note: Compounding fees are paid based upon the dosage form and

    route of administration information submitted on the pharmacy

    claim. To ensure proper payment, be certain to enter this

    information correctly.

    2 Compound Drug Pharmacy Claim Form (30-4) Completion Pharmacy 641 October 2006

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     Item Description

    22. DISPENSING UNIT FORM INDICATOR. Enter the appropriate code to indicate the way that the finished

    compound is measured.

Code Description

    1 Each

    2 Grams

    3 Milliliters

    23. ROUTE OF ADMINISTRATION. Enter the appropriate code to indicate the route by which the finished compound is

    administered to the recipient.

Code Description

    1 Buccal

    2 Dental

    3 Inhalation

    4 Injection

    5 Intraperitoneal

    6 Irrigation

    7 Mouth/Throat

    8 Mucous Membrane

    9 Nasal

    10 Ophthalmic

    11 Oral

    12 Other/Miscellaneous

    13 Otic

    14 Perfusion

    15 Rectal

    16 Sublingual

    17 Topical

    18 Transdermal

    19 Translingual

    20 Urethral

    21 Vaginal

    22 Enteral

Note: Compounding fees are paid based upon the dosage

    form and route of administration information submitted

    on the pharmacy claim. To ensure proper payment, be

    certain to enter this information correctly.

    2 Compound Drug Pharmacy Claim Form (30-4) Completion Pharmacy 572 December 2003

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     Item Description

    24. TOTAL CHARGE. Enter the total dollar and cents amount for

    this claim. This amount should include all compounding,

    sterility and professional fees. For intravenous and

    interarterial injections only, the fees should be multiplied by

    the number of containers before adding them to the total

    charge. Do not enter a decimal point (.) or dollar sign ($).

    For DMERC NCPDP hardcopy pharmacy crossovers, enter

    the Medicare Allowed Amount.

    Note: Compounding fees are paid based upon the dosage

    form and route of administration information submitted

    on the pharmacy claim. To ensure proper payment, be

    certain to enter this information correctly.

25. OTHER COVERAGE PAID. Optional item, unless Other

    Health Coverage (OHC) payment was received. Enter the full

    dollar amount of payment received from OHC carriers. Do not

    enter a decimal point (.) or dollar sign ($). Leave blank if not

    applicable. For DMERC NCPDP hardcopy pharmacy

    crossovers, add the Other Health Coverage Amount(s) and

    Medicare Paid Amount, enter the combined total.

26. OTHER COVERAGE CODE. Optional item, unless recipient

    has OHC. A valid Other Coverage code is required. Enter

    one of the following values:

    Code Explanation

    0 Not Specified or No Other Coverage Exists

    2 Other Coverage Exists, Payment Not Collected

    7 Other Coverage Exists, Claim was not covered

    or other coverage was not in effect at time of

    service

    9 Other Coverage Exists, Payment Collected

27. PATIENT’S SHARE (OF COST). Optional item, unless

    recipient paid Share Of Cost (SOC) for claim. Enter the full

    dollar amount of patient’s SOC paid by the patient on this

    claim. Do not enter a decimal point (.) or dollar sign ($).

    Leave blank if not applicable. For more information, see the

    Share of Cost (SOC): 30-1 for Pharmacy section in this

    manual.

    28. INCENTIVE AMOUNT. Optional item. If sterility testing was

    performed, enter the full dollar amount of the sterility test

    charge in this field. Do not enter a decimal point (.) or dollar

    sign ($). Leave blank if not applicable. For intravenous and

    interarterial injections only, the sterility testing fee should be

    multiplied by the number of containers.

    2 Compound Drug Pharmacy Claim Form (30-4) Completion Pharmacy 691 November 2008

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