Alaska Medicaid Pharmacy Quick Reference
~ revised 06/26/2014 ~
Topic
NCPDP
Description
Assistance Information
NCPDP D.0, Version/Format
Claims Processing Information
102-A2
Version/Release nu mber = D0
101-A1
BIN = 009661
104-A4
PCN = P013009661
301-C1
Group ID = AKMEDICAID
201-B1
Pharmacy ID = NPI (National Provider
Identifier)
302-C2
Cardholder ID = AK Medicaid / CAMA
Recipient ID #
411-DB
Prescriber ID = NPI
304-C4
Patient Date of Birth (mm/dd/yyyy)
305-C5
Patient Gender (Male = 1, Female = 2)
419-DJ
Prescription Origin Code (submit appropriate
code)
202-B2
Service Provider ID Qualifier = "01" (NPI)
466-EZ
Prescriber ID Qualifier = "01" (NPI)
Contact Magellan Technical Call Center at
800.884.3238 for questions.
ProDUR - NCPDP Message 88
ER – Early Refill
Early Refill: claims will deny if the following conditions not met
• 93% utilization required for narcotics,
• 75% for all other classes, and
• Accumulation of 7 days or less of the medication over the
past 120 days.
May contact Magellan Clinical Call Center for early
refill consideration at 800.331.4475.
DD – Drug/Drug Interaction
Claims will deny for interactions of the highest significance
TD – Therapeutic Duplication
Claims will deny for situations of therapeutic duplication
Refer to “DD, TD, PG overrides” below for additional
information on how to respond to the denial or contact
the Magellan Clinical Call Center for additional
assistance at 800.331.4475.
PG – Pregnancy Precautions
Claims will deny due to pregnancy precautions
Other
Other ProDUR alerts that are sent are “message only”.
Page 1
These messages accompany PAID claims and the
information is for the pharmacist’s review and
consideration.
Alaska Medical Assistance Provider Billing Manual: http://manuals.medicaidalaska.com/pharmacy/pharmacy.htm
Alaska Medicaid Pharmacy Quick Reference
~ revised 06/26/2014 ~
Topic
NCPDP
Description
Assistance Information
ProDUR - NCPDP Message 88 – cont’d
DD, TD, PG overrides
Providers may override claims that deny for DD, PG, and TD by
submitting the appropriate Professional Service (Intervention)
Code and Result of Service (Outcome) Code.
440-E5
Additional questions on these ProDUR edits may be
directed to the Magellan Clinical Call Center at
800.331.4475.
Professional Service Code
M0 = Prescriber consulted
PE = Patient education / instruction
PH = Patient medication history
P0 = Patient consulted
R0 = Pharmacist consulted other source
SW = Literature search / review
441-E6
Result of Service Code
1A = Filled, as is, false positive
1B = Filled prescription as is
1G = Filled, with prescriber approval
3B = Recommendation not accepted
3C = Discontinued drug
Page 2
Alaska Medical Assistance Provider Billing Manual: http://manuals.medicaidalaska.com/pharmacy/pharmacy.htm
Alaska Medicaid Pharmacy Quick Reference
~ revised 06/26/2014 ~
Topic
NCPDP
Description
Assistance Information
Prior Authorization (PA) Medications - NCPDP Message 75
Criteria Available at: http://dhss.alaska.gov/dhcs/Pages/pharmacy/medpriorauthoriz.aspx
Resources for Recipients: http://manuals.medicaidalaska.com/docs/dnld/Rx_Benefits_Authorization.pdf
Medication requires prior
authorization
If a claim denies for prior authorization, the patient and prescriber
need to be informed that the medication requires prior
authorization.
The “Information About Your Prescription Drug
Benefits and Prior Authorization” pamphlet is available
at the website above and is to be provided to members.
Hospice, LTC, Oncology overrides
For medications that permit PA overrides for Hospice, LTC,
Oncology, utilize the following override codes:
If an override does not go through, the medication
criteria may not permit overrides for Hospice, LTC, or
Oncology. Please contact the Magellan Clinical Call
Center at 800.331.4475.
Pharmacy level PA overrides
384-4X
Hospice = “11” (Patient Residence field)
384-4X
Long Term Care = “4” (Patient Residence field)
461-EU
Oncology = “2” (Prior Authorization Type Code
[PATC] field)
A subset of medications requiring prior authorization may be
overridden at the pharmacy level.
You may also consult the AK Medicaid DUR criteria
website for information on a specific medication.
Refer to the Billing Manual for specifics.
Preferred Drug List - NCPDP Message 75
PDL Criteria Available at: http://dhss.alaska.gov/dhcs/Pages/pdl/default.aspx
DUR Criteria Available at: http://dhss.alaska.gov/dhcs/Pages/pharmacy/medpriorauthoriz.aspx
Non-Preferred Drug overrides
Page 3
461-EU
Pharmacy may override a non-preferred medication
edit that has appropriate medical justification and
documentation and is not under utilization control
by entering an “8” in the Prior Authorization Type
Code (PATC) field.
For non-preferred medications under utilization control,
please refer to the medication’s specific criteria on the
AK Medicaid DUR criteria website.
For questions, contact the Magellan Clinical Call Center
at 800.331.4475.
Alaska Medical Assistance Provider Billing Manual: http://manuals.medicaidalaska.com/pharmacy/pharmacy.htm
Alaska Medicaid Pharmacy Quick Reference
~ revised 06/26/2014 ~
Topic
NCPDP
Description
Assistance Information
Quantity Limits - NCPDP Message 76
Criteria Available at: http://dhss.alaska.gov/dhcs/Pages/pharmacy/medpriorauthoriz.aspx
Hospice, LTC, Oncology overrides
For medications that permit Quantity Limit overrides for Hospice,
LTC, Oncology
384-4X
Hospice = “11” (Patient Residence field)
384-4X
Long Term Care = “4” (Patient Residence field)
461-EU
Oncology = “2” (Prior Authorization Type Code
[PATC] field)
If override does not go through, the medication criteria
may not permit overrides for Hospice, LTC, or
Oncology. Please contact the Magellan Clinical Call
Center at 800.331.4475.
You may also consult the AK Medicaid DUR criteria
website for additional information.
Dispensing Fees – 7 AAC 145.410
Page 4
On Road
$13.36, not more than once every 22 days per
covered outpatient drug (COD)
Off Road
$21.28; nmt once every 22 days per COD
Out of State
$10.76; nmt once every 22 days per COD
Mediset
Pharmacy
$16.58, nmt once every 14 days per COD
Compounded
Outpatient
Drug
Assigned fee based on hierarchy above
Dispensing
prescriber
$0.00
The dispense fee paid will be the lesser of the assigned
dispense fee (noted to the left) or the dispensing fee
submitted by the pharmacy.
Contact the Magellan Technical Call Center with any
questions: 800.884.3238
Alaska Medical Assistance Provider Billing Manual: http://manuals.medicaidalaska.com/pharmacy/pharmacy.htm
Alaska Medicaid Pharmacy Quick Reference
~ revised 06/26/2014 ~
Topic
NCPDP
Description
Assistance Information
Compounds and Home Infusion – 7 AAC 120.110
Multi-ingredient Compounds:
Home Infusion Therapy Claims:
Compounds must contain a covered outpatient drug to be eligible
for reimbursement.
407-D7
Product/Service ID field = “0”
436-E1
Product/Service ID Qualifier field = “00”
406-D6
Compound Code field = “2”
420-DK
Submission Clarification Code field
8 = Process Compound For Approved Ingredients only if
you are willing to accept payment for one covered
product. Using this code will not bypass drug not
covered or PA rejections. These medications will not be
reimbursed.
Contact the Magellan Technical Call Center with any
questions at 800.884.3238.
Submit as multi-ingredient compound as above and include the
following
995-E2
Route of Administration field = “424109004”
450-EF
Compound Dosage Form Description Code field =
“11” (solution)
384-4X
Dispense fee available only if patient is Long Term
Care (Patient Residence Field = “4”)
Copayments – 7 AAC 105.610(a)(4)
Claim Payment Amount ≤ $50
Copay = $0.50
Claim Payment Amount > $50
Copay = $3.50
Eligible recipients under 7 AAC
48.560 or vaccines administered
by a pharmacist
Copay = $0.00
Page 5
Contact the Magellan Technical Call Center with any
questions: 800.884.3238
Alaska Medical Assistance Provider Billing Manual: http://manuals.medicaidalaska.com/pharmacy/pharmacy.htm
Alaska Medicaid Pharmacy Quick Reference
~ revised 06/26/2014 ~
Topic
NCPDP
Description
Assistance Information
Other Fees – 7 AAC 145.410
Tobacco Cessation Counseling Fee
No more than once every 30 days; $16.00
438-E3
Vaccine Administration Fee
Postage or Shipping Charges
Incentive Amount Submitted field
Contact the Magellan Technical Call Center with any
questions: 800.884.3238
Eligible if in compliance with 12 AAC 52.240 and 7 AAC
110.405(b)(2) and (3); $17.46
480-H9
Other Amount Claimed Submitted field
479-H8
Other Amount Claimed Submitted Qualifier = “04”
412-DC
Dispensing Fee Submitted field = “0.00” or “null”
Not to exceed $16 per prescription; allowed only if pharmacy ships
a medication to a recipient and pharmacy services are not available
in the recipient’s community; if multiple prescriptions are shipped
together, the shipping cost is to be divided by the number of
prescriptions; the divided cost is billed on each applicable claim,
not to exceed $16 per package shipped.
480-H9
Other Amount Claimed Submitted field
479-H8
Other Amount Claimed Submitted Qualifier = “03”
(Postage Cost)
90 Day Drug List
Criteria Available at: http://dhss.alaska.gov/dhcs/Documents/pharmacy/pdfs/90-Days-supply-medication-list.pdf
Medications on the Alaska Medicaid 90 Day Generic Prescription
Medication List may be dispensed up to a 90 day supply when a
prescriber’s order authorizes. No more than a single dispense fee
shall be paid. ** Note: Products packaged in three month supplies
will not be allowed unless they are generic. **
Page 6
Contact the Magellan Clinical Call Center with any
questions: 800.331.4475
Alaska Medical Assistance Provider Billing Manual: http://manuals.medicaidalaska.com/pharmacy/pharmacy.htm
Alaska Medicaid Pharmacy Quick Reference
~ revised 06/26/2014 ~
Topic
NCPDP
Description
Assistance Information
Coordination of Benefits – 7 AAC 145.400
Resources Available at: http://manuals.medicaidalaska.com/docs/dnld/AK_D0_Payer_Specs_05062014_B1-B2_Only.pdf
http://manuals.medicaidalaska.com/docs/dnld/TPL_pharmacy.pdf
Other
Coverage Code
(OCC)
State of Alaska only permits submission of the following:
Other Payer
Patient
Responsibility
Amount
When other coverage exists, the Department will pay the lesser of
the difference between the third-party payment amount and the
Medicaid allowed amount or the submitted patient responsibility
amount from the primary.
Discrepancy
between OCC
and Other
Payer Amount
Paid
NCPDP 7K
Other Payer
Amount Paid
less than $1.00
NCPDP 70
Page 7
308-C8
0 = Not Specified by patient
2 = Other coverage exists-payment collected
3 = Other Coverage Billed – claim not covered
4 = Other coverage exists-payment not collected
353-NR
Other Payer Patient Responsibility Amount Count
351-NP
Other Payer Patient Responsibility Amount
Qualifier
352-NQ
Other Payer Patient Responsibility Amount
If the system sees that another payer paid something on the claim,
the OCC submitted must match otherwise the claim will deny.
308-C8
2 = Other coverage exists-payment collected
431-DV
Other Payer Amount Paid
Claims will deny when the amount paid by the Other Payer is less
than $1.
431-DV
Refer to Payer Specs or contact the Magellan Technical
Call Center with any questions at 800.884.3238.
Refer to Payer Specs or contact the Magellan Technical
Call Center with any questions at 800.884.3238.
Contact the Magellan Technical Call Center at
800.884.3238 with any questions.
Contact the Magellan Technical Call Center at
800.884.3238 to request an override.
Other Payer Amount Paid
Submit bill to
other pay
Recipient has other insurance on file. Claim has not been costavoided against all other payers.
NCPDP 41
339-6C
Other Payer ID Qualifier
340-7C
Other Payer ID – two-digit carrier code
If recipient claims there is no other insurance, contact
the Xerox Call Center for assistance.
Alaska Medical Assistance Provider Billing Manual: http://manuals.medicaidalaska.com/pharmacy/pharmacy.htm
Alaska Medicaid Pharmacy Quick Reference
~ revised 06/26/2014 ~
Topic
NCPDP
Description
Assistance Information
411-DB
Prescribers must be enrolled with Alaska Medicaid
in order for claims to be paid; prescriber ID sent as
NPI.
Contact the Xerox Call Center 800.770.5650
201-B1
Providers must be enrolled with Alaska Medicaid in
order for claims to be paid; prescriber ID sent as
NPI.
Enrollment / Eligibility Issues
Non-matched
Prescriber ID
NCPDP 56
Provider not
contracted on
DOS
NCPDP 40
Filled after
Coverage
Terminated
Recipient’s eligibility in the system indicates
coverage not active.
NCPDP 69
State Maximum Allowable Cost – 7 AAC 145.400
NADAC
Effective 07/01/14, NADAC will become the State
Maximum Allowable Cost for all products with a
NADAC price type available. A separate AK-specific
MAC may be maintained for specialty medications and
those that do not have NADAC price types available. A
form will be available on:
Once pharmacies have called the Magellan Clinical Call
Center to confirm that the claim paid at NADAC,
pharmacy providers may contact the contractor to the
Centers for Medicare & Medicaid Services for
managing NADAC, Myers and Stauffer LC, via phone
or email to initiate a NADAC price review.
http://manuals.medicaidalaska.com/pharmacy/pharmacy.htm
Phone: 855.457.5264
Email: [email protected]
All other claims processing issues, including pricing
and payments not related to NADAC prices, should be
directed to the Magellan Clinical Call Center at
800.331.4475.
Page 8
Alaska Medical Assistance Provider Billing Manual: http://manuals.medicaidalaska.com/pharmacy/pharmacy.htm