2.4 Electronic Claims Capture and Adjudication (ECCA) (Rev. 11/02)

The Electronic Claim Capture and Adjudication feature is optional. Providers may elect to have their on-line claims captured electronically by the eMedNY contractor for editing and final adjudication.

Captured claims will be fully edited for completeness and validity of the format of the entered data. There is a possibility that claims captured by the eMedNY contractor for final adjudication may be pended and subsequently denied. When a captured claim is pended, final adjudication results will appear on the remittance statement produced from the eMedNY contractor processing cycle in which the claim either approved for payment or denied. All claim processing edits are performed during the adjudication process. An advantage of ECCA is that it saves the pharmacy from having to file the claims separately.

Pharmacies that choose to use the ECCA option must select a Personal Identification Number (PIN) and forward that number to NYSDOH for processing. The PIN selection form can be found in the FORM section at the end of this manual. Additionally, the pharmacy must also have a Transmission/Transmittal Supplier Number (TSN) (a/k/a Magnetic Supplier Number) on file with the eMedNY contractor. To obtain a TSN, or for more information, call (518) 447-9256. Remittances for claims submitted for ECCA will be returned to you via the media you select for that TSN. If you use your service bureau's TSN, a paper remittance will automatically be returned to you. If you choose your own TSN, you can select paper or tape remittance. Once the eMedNY contractor has assigned you a TSN, you must complete a Certification Statement, have it notarized and returned to the eMedNY contractor. The Certification Statement can be found in the FORM section at the end of this manual.

If you wish your claim electronically captured, you must enter the required data in the Processor Control Number field. The required data is the Read Certification Statement, Pharmacist's Initials, PIN, and TSN. Further details of all input fields are explained in the input data section of this manual. If you are submitting via the variable 32 format, the Pharmacist's Identification field can also be used to enter the pharmacist's initials in lieu of entering them in the Processor Control Number Field. Some software vendors and switch companies have the pharmacy enter this information in fields other than the Processor Control Number field. This is OK as long as they forward it to the eMedNY contractor in the Processor Control Number field.

If the Processor Control Number field is completed properly and the claim is not rejected for an edit, an invoice number is assigned to the claim. This 9-digit number will be returned in the Authorization Number field of the response. Only one invoice number will be returned for a transaction, which could include up to four claims. The invoice number will appear on your remittance statement. If the Processor Control Number field is completed and an invoice number was not returned in the Authorization Number field, the system will return NO CLAIM TO FA indicating that the claim was captured for Service Authorization but not processed for adjudication by the eMedNY contractor.

If a claim has passed all eligibility, UT, P&C, claim history, DUR and DVS editing, a "C" is returned in the response. The NCPDP definition of "C" is Claim Captured. Some software packages may translate this code into words. The only time a claim has been captured for adjudication is if you see an authorization (invoice) number in your response. Claims that have an Authorization Number assigned online do not have to be submitted on paper or magnetic media. Please note and retain the authorization number of the claim for your records, as the eMedNY contractor may require it for problem investigation. Only claims that do not have an Authorization Number assigned will have to be submitted by the provider directly to the eMedNY contractor, via paper or mag media.

The following types of claims cannot be submitted to the eMedNY contractor for ECCA.

1. An original claim with a date of service more than ninety days old. However, claims over ninety days old will be processed for eligibility, UT and P&C service authorizations, but they need to be sent to the eMedNY contractor on paper or magnetic media with appropriate over ninety day reason indicated. Rebills and reversals are allowed to be submitted ECCA with service dates up to two years old.

2. Compound Prescription Drugs. Although each ingredient can be billed on a per line item basis via ECCA, a transaction for any other compound billing method will be automatically converted to non-ECCA.

3. Durable Medical Equipment (DME) claims. DME includes any claim identified by Specialty Code 307 or Category of Service 0442. Please Note: DME does NOT include the product supply codes (1 alpha, 4 numeric) found in the MMIS Pharmacy Provider Manual pages 4-9 through 4-31. These codes can be submitted for ECCA using the variable 32 format where the alternate product type and alternate product code fields are available for submission.

4. Fixed Format (3A) Only: Because Other Payor Amount (Field 431) is not available, third party insurance claims will not be captured, but a service authorization will be created by the eMedNY contractor.

5. A Dispensing Validation System (DVS) transaction for an item that is only reimbursable under category of service 0442 (DME). Items reimbursable under category of service 0441 (Rx) will be processed for ECCA if the claim is billed without the 307 (DME) designated specialty code and the Processor Control Number is properly completed.

2.5 Third Party Claims (Rev. 11/02)

A recipient's other insurance information (if any) is returned to you in the on-line response via the Additional Message field. If the recipient's other insurance covers drugs, either H, K, M, O or the word ALL will be returned in the Insurance Coverage Code position of the Additional Message Field.

For a third party claim to be successfully captured for ECCA via the variable 32 format, the Other Coverage Code field (308) and Other Payor Amount field (431) must be entered. It is extremely important that you make sure that the value entered in the Other Coverage Code field corresponds to the entry in the Other Payor Amount field. The entry in each field must correlate to the other field and be logically correct for your claim to be accepted.

Please Note: The Other Payor Amount Field is an optional field and should not be submitted unless the recipient has other drug coverage and you have received reimbursement or been notified that the service is not covered by the other insurance company.

Third party drug claims can be processed on-line for the UT, P&C, and DUR service authorizations using the variable 32 or fixed 3A NCPDP formats. However, for ECCA, the claim must be submitted using the variable 32 format since the Other Payor Amount field is not available in the fixed format. If a claim is submitted via the fixed format and the recipient has third party drug coverage; the claim will be processed for all applicable service authorizations but not for ECCA. If ECCA is requested, a 'NO CLAIM TO FA' will be returned in the Authorization Number field and the claim must be forwarded to the eMedNY contractor on paper or magnetic media.

The values for field 308 (Other Coverage Code) are:

0 = Not Specified

1 = No Other Coverage Identified

2 = Other Coverage Exists - Payment Collected

3 = Other Coverage Exists - This Claim Not Covered

4 = Other Coverage Exists - Payment Not Collected

There are several edits in place to ensure that logical entries are made in both field 308 and 431. The charts, on the following page, describe what the status of the claim will be based on the field entries. The edits on Chart #1 will occur when the recipient has MEVS Insurance Coverage Codes H, K, M, O or ALL on file with the eMedNY contractor. Chart #2 will occur when no MEVS Insurance Coverage Codes indicating Pharmacy coverage for the recipient are on file.

Please Note: Since field 431 is not available in the fixed RTDS "A" format, third party claims can only be captured for ECCA using the variable format. However, all Service Authorizations can still be obtained for Third Party claims using the Fixed Format.

Chart 1 – Recipient with Coverage Codes H, K, M, O or ALL on file

Field 308 Value	Field 431 Value	NCPDP Format Version	Field 104 Value	Claim Status
0, 1, 2, 3, or 4	431 is Not sent (spaces)	32 (variable) or 3A (fixed)	Non-ECCA (Processor Control Number not sent) or ECCA (Processor Control Number sent)	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 501) and “NO CLAIM TO FA” (field 503) will be returned).
0, 1 or 4	Zeros or greater	32	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code: 13 “M/I Other Coverage Code” and Response Code: 717 “Client Has Other Insurance” will be returned on-line.
2	Zeros	32	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code 13 “M/I Other Coverage Code” and Response Code 715 ‘Other Payor Amount Must Be Greater Than 0’ will be returned.
2	Greater than Zero	32	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 501) and an invoice number (field 503) will be returned). Other payor amount will be subtracted from the claim’s payment amount.
2	Greater than Zero	32	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 501) and “NO CLAIM TO FA” (field 503) will be returned).
3	Zeros	32	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 501) and an invoice number (field 503) will be returned).
3	Zeros	32	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 501) and “NO CLAIM TO FA” (field 503) will be returned).
3	Greater than Zero	32	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code “13 M/I Other Coverage Code” and Response Code “716 ‘ Other Payor Amount Must Be Equal to 0” will be returned.

Chart 2 - Recipient without Coverage Codes on file

Field 308 Value	Field 431 Value	NCPDP Format Version	Field 104 Value	Claim Status
0, 1, 2, or 3	Not sent	32 or 3A	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 501) and “NO CLAIM TO FA” (field 503) will be returned).
0 or 1	Not sent	32 or 3A	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 501) and an invoice number (field 503) will be returned).
0, 1, or 3	Zeros	32	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 501) and “NO CLAIM TO FA” (field 503) will be returned).
0, 1, or 3	Zeros	32	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 501) and an invoice number (field 503) will be returned).
0, 1, 3, or 4	Greater than Zero	32	Non-ECCA or ECCA	The transaction will be rejected. NCPDP Reject Code “DV - M/I Other Payor Amount” and Response Code “320 – Other Insurance Information Inconsistent” will be returned.
2 or 3	Not sent	32 or 3A	Non-ECCA or ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 501) and “NO CLAIM TO FA” (field 503) will be returned).
4	Not sent or zeros	32 or 3A	Non-ECCA or ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 501) and “NO CLAIM TO FA” (field 503) will be returned).
2	Greater than Zero	32	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 501) and “NO CLAIM TO FA” (field 503) will be returned).
2	Greater than Zero	32	ECCA	If all other edits are passed, the transaction will be accepted for payment. (“C - capture” (field 501) and an invoice number (field 503) will be returned).
2	Zeros	32	Non-ECCA or ECCA	The claim will reject. NCPDP Reject Code “13 M/I Other Coverage Code” and Response Code “715 Other Payor Amount Must Be Greater Than 0” will be returned.

2.6 Rebills/Adjustment Information (Rev. 11/02)

Rebills will be processed as adjustments to a previously submitted claim that was approved for payment. Rebills cannot be submitted for claims that are pending or were rejected.

NCPDP standards dictate that a rebill must be submitted with a Transaction ID (Field 103) value of 31 through 34. The number of claim lines contained within the transaction is indicated by the second digit. (If one claim line is contained in the transaction, the Transaction ID should be 31. If four claim lines are contained in the transaction, the Transaction ID should be 34).

Although you will need to submit all fields required for the original claim transaction, your claims will be matched to the original claim using: Medicaid Provider Identification Number, Prescription Number, and Date Filled. If by chance these fields do not define uniqueness, meaning that more than one active claim meeting the criteria resides on the eMedNY contractor’s claims history file, the most recently submitted claim will be selected for adjustment. If you are trying to adjust the older submission, you will need to submit the rebill via paper or magnetic media where you can supply the Claim Reference Number of the specific claim you are trying to adjust.

Both the fixed and variable NCPDP formats can be used. Rebill transactions can be submitted for service dates up to two years old if the original transaction was submitted directly to the eMedNY contractor. This includes paper and magnetic media, as well as online claim submissions.

If the rebill is adjusting a paid claim, the rebill will appear on your remittance statement. If the rebill is adjusting a paid claim, you must complete the Processor Control Number field.

You can not adjust a non-ECCA claim to become an ECCA claim. The adjustment will apply any updated information, but the adjustment claim will remain a non-ECCA claim and the NO CLAIM TO FA response will be returned to you. If the rebill is adjusting a non-ECCA transaction, the rebill will not appear on your remittance statement.

Rebills will not affect previously established service authorization limits.

Rebills will not be allowed for original claims that generated a DVS prior approval. If a change is needed to a paid DVS claim, then you can submit the adjustment on paper or magnetic media. You may also reverse the original claim and then submit another original transaction with the corrected information.

2.8 Alternate Product Codes (Rev. 04/03)

These codes are also referred to as Sickroom Supplies, "Z" codes, or DME item codes and consist of a 5 digit alpha-numeric code. The valid codes can be found on pages 4-9 through 4-31 of the MMIS Pharmacy Provider Manual. For DVS transactions, some of the item codes are only in the DME Provider Manual since they are only reimbursable under COS 0442 (DME).

The 5 digit alpha-numeric codes must be submitted in the Alternate Product Code (APC) field using the NCPDP variable 32 format. If the code is submitted in the NDC field, your claim will be rejected.

The NCPDP fixed RTDS 3A format does not contain an APC field. If you are using the fixed format, you will not be able to send an APC claim for ECCA processing. However, you can use the 3A format to obtain a UT/P&C service authorization for the APC codes by putting zeroes in the NDC Code field and a zero in the Compound Code field. The claim will not be captured for adjudication. The provider must submit the claim directly to the eMedNY contractor on paper or magnetic media.

If using the variable 32 format for submitting APC claims, make sure that the fields specified below are correctly completed as indicated:

FIELD	CONTENTS
Compound Code	Must contain a zero or one. Use zero for DVS transactions.
Alternate Product Type	Must contain a value of one.
Alternate Product Code	13 characters in length. The first six positions must contain zeroes followed by the 5-character alpha/numeric code. The last two positions must contain blanks or BO modifier.
NDC Code	Must contain zeroes.

A correct entry in the Alternate Product Code field would look as follows:

0000Z2500bbbb

(where bbbb equals four blanks or BO modifier and 2 blanks)

000000Z2500bb

(where bb equals two blanks or BO modifier)

2.9 APC Quantities (Rev. 11/02)

Be aware that the Quantity/Size listed in the MMIS Provider Manual for each APC code is not usually the quantity that should be entered in the Metric Quantity field. The quantities listed in the manual refer to ounces, milligrams, sizes, units or the number contained in each unit (box, package, bottles, etc). The entry in the Metric Quantity field should be the number of units dispensed.

The following examples are listed to help clarify the correct Metric Quantity entries.

APC		QUANTITY SIZE IN MANUAL	METRIC QUANTITY FIELD ENTRY	MAX QUANTITY
Z2001	Butterfly Clamps	100's (up to 1)	00001 (1 box dispensed)	1 box
Z2003	Plastic Strips	30's	00002 (2 boxes of 30 dispensed)	5 boxes
Z2012	Adhesive Tape	2" x 5 yd	00003 (3 rolls dispensed)	5 rolls
A4244	Alcohol or peroxide per pint	473 ml	00001 (1 pint bottle dispensed)	5 bottles
A4215	Needles	each (up to 100)	00056 (56 needles dispensed)	100 needles
A4635	Underarm pad crutch replacement	each (up to 2)	00001 (1 pad dispensed)	2 pads

Enteral Products

The metric quantity for enteral products should be entered as caloric units. For example: A prescription is for Regular Ensure 1-8 oz. can/day, 30 cans with five refills. There are 75 caloric units per 30 cans (one month supply). The correct entry for the current date of service is 00075. Do not include refills.

Please Note: The metric quantity entry examples shown contain 5 digits because the NCPDP field requires a five digit entry. New York State only accepts 4 digits at this time. Your software may only be requiring you to enter 4 digits which is OK as long as they add the leading zero when submitting the transaction in order to comply with NCPDP field length.

2.10 Dispensing Validation System (Rev. 04/03)

This function enables suppliers of predesignated enteral nutrition products, for prescriptions written prior to date of service 4/1/03, prescription footwear items, specified drugs, certain medical surgical supplies and durable medical equipment to receive a prior approval number (DVS number) through an automated electronic MEVS system. The DVS transaction can be submitted through the NCPDP variable 3.2 format. For fixed RTDS-3A format, DVS is allowed for NDC codes only since the alternate product code field is not available. The claims processing system will recognize an item/NDC code requiring a DVS number and will process the transaction through all required editing. If approved, and if the item/NDC code is reimbursable under category of service 0441, 0161 or 0288, the DVS number will be returned in response field 526 and the claim will be processed for adjudication (if ECCA is requested). Only items reimbursable under Category of Service 0441, 0161 or 0288 (Rx) will be processed through ECCA. Items, which are only reimbursable under Category of Service 0442 (DME), can be submitted through NCPDP, but must be billed on DME Claim Form C. Be sure to put the DVS number from Field 526 on the claim form.

Important Information Regarding DVS Transactions

· Transactions for both NDC’s and APC’s can be submitted using the variable 3.2 format. Only NDC can be submitted through the fixed RTDS-3A format.

· Although multiple claim line transactions (02, 03, or 04) can be submitted, only one DVS claim line item can be submitted per transaction and the DVS line must be the first line item within the transaction.

· Required claim fields for a DME Category of Service 0442 transaction are:

404 - Metric Quantity

406 - Compound Code, Value 0

411 - Prescriber ID

421 - Primary Prescriber

436 - Alternate Product Type

437 - Alternate Product Code

Note: There may be some items where you are specifically instructed by New York State to use the 11 digit National Drug Code. If this occurs, use field 407 (NDC) in lieu of field 436 and 437. Field 406 value should then be 1.

In addition to the other required header transaction fields, Field 201 must contain the Category of Service on your file that you will be billing under. Valid Categories of Service are:

0161 - Clinic Pharmacy

0288 - Hospital Based Pharmacy

0441 - Pharmacy

0442 - Pharmacy DME

· Item codes that require a DVS number will not be processed through the UT, P & C or DUR programs. Prescription Drugs that require a DVS number will be subject to UT, P & C and DUR processing.

· Only current dates of service will be accepted for DVS transactions.

2.14 Duplicate Claim Transactions (Rev. 11/02)

When an online claim transaction is sent to the MEVS, it will be matched against previously captured (approved) claims. If the transaction is determined to be an exact duplicate of a previously approved claim, the MEVS will return a “C” in the Claim Response Field 501. The remaining response fields will contain the data that was returned in the original response. The following fields will be examined to determine if the original captured response will be issued:

· Pharmacy Number (201 positions 21-28)

· Cardholder ID Number (302)

· Date Filled (401)

· Prescription Number (402)

· New/Refill Code (403)

· P.A./M.C. Number (416 positions 2-9)

· and if not a compound, either the NDC Number (407)or Alternate Product Code (437).

If identical data exists only in certain subsets of the above fields, your claim will be rejected for NCPDP Reject Code 83 “Duplicate Paid/Captured Claim” unless prior approval was obtained for one of the two conflicting transactions (meaning field 416 Prior Authorization/Medical Certification Code/Number would need to contain a PA Number on one claim, and no PA Number for the other claim.)

For example, a NCPDP Reject Code of 83 “Duplicate Paid/Captured Claim” is returned when a claim is submitted and the Pharmacy Number, Cardholder ID, and Prior Approval Number fields match a previous paid claim and one of the following conditions also exists:

· Prescription Number matches, but NDC/APC is different.

· NDC/APC (if not a compound) matches, but Prescription Number is different.

· Prescription Number and New/Refill Code is the same, but the Date Filled is different.

If the original transaction was non-ECCA and the duplicate transaction is ECCA, the transaction response will be the original non-ECCA response. No adjudication process will occur.

3.0 Pro-DUR PROCESSING (Rev. 11/02)

A drug history profile is maintained for all recipients. This file contains a record for each accepted prescription or OTC item entered through the ProDUR system. Each prescription on the drug profile is assigned an expiration date. This date is calculated using the date filled plus the days supply.

All prescription and OTC transactions are compared to the recipient's drug profile. If the new prescription falls within the active date range (date filled plus days supply) and a conflict exists, a DUR response will be returned. ProDUR editing is not performed on compound drugs or sickroom supplies. DUR editing will also be performed for the majority of the denial codes on Tables 2,7,8, and 9.

The DUR edits are based on the clinical database compiled by First DataBank. This information is used to administer the New York State Medicaid Pro-DUR program under the direction of the DUR Board.

Up to three (3) DUR related conflicts can be identified and returned for each drug submitted. Information about these conflicts is returned in the response in order of importance. In cases where more than three conditions are identified, a DUR Overflow indicator is also returned.

Conflicts detected by the Pro-DUR editing may result in reject or warning conditions. At present, there are only two conditions that will cause a requested drug to be rejected: clinical significance (severity) one (1) condition from the Therapeutic Duplication edit and clinical significance one (1) condition from the Drug-Drug Interaction edit. Any other DUR response is a warning and will not cause the claim to be rejected. If a DUR reject is returned for a drug, no DUR, UT, P&C, or DVS authorizations will be retained for the claim. In order to get the necessary authorizations from the Pro-DUR system to dispense a drug that has been rejected by the DUR edits, an override request must be submitted. Overrides are discussed further in the Override Processing section.

The following series of edits are performed by the Pro-DUR system:

Therapeutic Duplication (TD)

The Therapeutic Duplication edit checks the therapeutic class of the new drug against the classes of the recipient's current, active drugs already dispensed.

Drug-Drug Interactions (DD)

The Drug-Drug Interaction edit matches the new drug against the recipient's current, active drugs to identify clinically relevant interactions.

Drug-Disease Contraindications (DC)

The Drug-Disease Contraindications edit determines whether the new drug is potentially harmful to the individual's disease condition. The active drugs on drug history determine the recipient’s disease condition(s).

Drug Pregnancy Alert (PG)

Drug Pregnancy Alert warnings are returned for females between the ages of 13 and 52 on new drugs that may be harmful to pregnant women.

Pediatric Precautions (PA)

Pediatric Precautions are returned for children under the age of eighteen (18) on new drugs that may be harmful to children.

Lactation Precautions (PG)

Lactation Precautions are returned for females between the ages of 13 and 52 on new drugs that may be harmful to nursing women or their babies.

Geriatric Precautions (PA)

Geriatric Precautions are returned for adults over the age of 60 on new drugs that may be harmful to older adults.

High Dose Alert (HD)

A High Dose Alert is returned if the dosage for the new drug exceeds the maximum dosage recommended for the recipient's age group.

Low Dose Alert (LD)

A Low Dose Alert is returned if the dosage for the new drug is below the minimum dosage recommended for the recipient's age group.

Call Provider Services (CH)

If this response is received, there may be a need for further explanation of the free text. If so, contact Provider Services at 1-800-343-9000.

3.1 DUR Response Fields (Rev. 11/02)

The following information is returned in the response from the Pro-DUR system for each identified DUR conflict:

Drug Conflict Code

Clinical Significance

Other Pharmacy Indicator

Previous Date of Fill

Quantity of Previous Fill

Database Indicator

Other Prescriber Indicator

Free Text

Drug Conflict Code

The Drug Conflict Code identifies the type of DUR conflict found when a new prescription is compared against the recipient's drug history file and demographics. Following are the values that may be returned as Drug Conflict Codes:

TD = Therapeutic Duplication

DD = Drug-Drug Interactions

DC = Inferred Drug Disease Precaution

PG = Drug Pregnancy Alert

PA = Drug Age Precaution

LD = Low Dose Alert

HD = High Dose Alert

CH = Call Provider Services (1-800-343-9000)

Clinical Significance

The Clinical Significance is a code that identifies the severity level and how critical the conflict. The following chart lists each drug conflict code and the clinical significance codes which may be returned for that code as well as whether they are DUR rejects or warnings.

Conflict Code	Reject/ Warning	Clinical Significance	Description of Clinical Significance
TD Therapeutic Duplication	R	1	An Original Prescription that duplicates a therapy the recipient is already taking.
	W	2	Prescription is a Refill and is being filled prior to 75% of the prior script's days supply.
DD Drug-Drug	R	1	Most significant. Documentation substantiates interaction is at least likely to occur in some patients, even though more clinical data may be needed. Action to reduce risk of adverse interaction usually required.
	W	2	Significant. Documentation substantiates interaction is at least likely to occur in some patients, even though more clinical data may be needed. Assess risk to patient and take action as needed.
	W	3	Possibly significant. Little clinical data exists. Conservative measures are recommended because the potential for severe adverse consequences is great.
DC Drug Disease	W	1	Absolute Contraindication. Drug Therapy for the recipient should be changed.
	W	2	Precaution. The risk/benefit of therapy should be considered and the recipient's response closely monitored.
PG Pregnancy	W	D	PREGNANCY There is positive evidence of human fetal risk based on adverse reaction data from investigation or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
	W	X	PREGNANCY Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigation or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.
	W	1	PREGNANCY No FDA rating but is contraindicated or not recommended; may have animal and/or human studies or pre- or post-marketing information.
	W	1	LACTATION Absolute Contraindication. The Drug should not be dispensed.
	W	2	LACTATION Precaution. Use of the Drug should be evaluated carefully.
PA Drug Age	W	1	Absolute Contraindication. Drug Therapy should be changed.
LD Low Dose	W	1	Prescribed dose is less than the minimum appropriate for the drug.
HD High Dose	W	1	Prescribed dose is greater than the maximum appropriate for the drug.
CH Call Provider Services	W	1	Further explanation may be required. Call 1-800-343-9000.

Other Pharmacy Indicator

The following values may be returned in the Other Pharmacy Indicator:

0 = Not Specified

1 = Your Pharmacy

3 = Other Pharmacy

Previous Date of Fill

The Previous Date of Fill provides the date the conflicting drug was dispensed.

Quantity of Previous Fill

The Quantity of Previous Fill provides the quantity of the conflicting drug.

Database Indicator

The Database Indicator will always be returned with a value of 1 to indicate that First DataBank is the DUR database provider.

Other Prescriber Indicator

The Other Prescriber Indicator compares the Prescriber of the current prescription to the Prescriber of the conflicting drug from the recipient's active drug profile, and returns one of the following codes:

0 = Not Specified

1 = Same Prescriber

2 = Other Prescriber

Conflict Code Free Text Descriptions

A Free Text message is returned for each conflict to provide additional information about the DUR condition. Following is a description of the Free Text:

CODE	FREE TEXT DESCRIPTION
TD	For Clinical Significance 1, the name, strength, dose form and day’s supply of the conflicting drug from the Drug Profile.
	*Example*
	TD 1 1 20020926 00030 1 PROPRANOLOL 10MG TABLET 030

	For Clinical Significance 2 the words WARNING - EARLY REFILL MMDDYY

	*Example*
	TD 2 1 20020929 00030 1 WARNING – EARLY REFILL 10/22/02
	Note: MMDDYY is the earliest date that the refill should be filled.
DD	Will contain the Clinical Effect Code followed by the Drug Name from the Drug Profile of the drug interacting with the new prescription being filled. The latter drug will be the new prescription drug and the former drug will be the drug from the Drug Profile. The Clinical Effect Code will consist of one of the following values: Examples of each Clinical Effect code is included.
	INF Increased effect of former drug

	*Example*
	DD 2 1 20021011 00030 1 INF DIGITALIS/KALURETICS

	DEF Decreased effect of former drug

	*Example*
	DD 2 1 20021012 00030 1 DEF CORTICOSTEROIDS/BARBITURAT

	INL Increased effect of latter drug

	*Example*
	DD 3 1 20021003 00030 1 INL VERAPAMIL/DIGOXIN

	DEL Decreased effect of latter drug

	*Example*
	DD 2 1 20020920 00060 DEL NSAID/LOOP DIURETICS

	ARF Adverse reaction of former drug

	*Example*
	DD 2 1 20021018 00090 1 ARF THEOPHYLLINES/TICLOPIDINE

	ARL Adverse reaction of latter drug

	*Example*
	DD 1 1 20021014 00050 1 ARL NSAID/TRIAMTERENE

	MAR Adverse reaction of both drugs

	*Example*
	DD 2 1 20020920 00090 1 MAR ACE INHIBITORS/POTASS.SPAR

	MXF Mixed effects of former drug

	*Example*
	DD 2 1 20021018 00015 1 MXF ANTICOAGULANTS,ORAL/ANTITH

	MXL Mixed effects of latter drug

	*Example*
	DD 2 1 20020919 00060 1 MXL HYDANTOINS/DISOPYRAMIDE

DC	The description of the drug/disease contraindication.

	*Example*
	DC 1 1 20020914 00090 1 HYPERTENSION

PG	For pregnancy precautions the words PREGNANCY PRECAUTION

	*Example*
	PG 1 0 00000000 00000 0 PREGNANCY PRECAUTION

	For lactation precautions the words LACTATION PRECAUTION

	*Example*
	PG 2 0 00000000 00000 0 LACTATION PRECAUTION

PA	For pediatric precautions the word PEDIATRIC

	*Example*
	PA 1 0 00000000 00000 0 PEDIATRIC

	For geriatric precautions the word GERIATRIC

	*Example*
	PA 1 0 00000000 00000 0 GERIATRIC

LD	For low dose precautions the recommended minimum and maximum dosage will be shown.

	*Example*
	LD 1 0 00000000 00000 0 3.000 12.000

HD	For high dose precautions the recommended minimum and maximum dosage will be shown.

	*Example*
	HD 1 0 00000000 00000 0 1.000 8.00

CH*	Call Provider Services if further explanation needed.

	*Example*
	(to be determined)

	* Code CH is not currently returned but may be returned in the response in the future if a condition arises to necessitate its return.

4.0 OVERRIDE PROCESSING (Rev. 11/02)

4.1 DUR Override (Rev. 11/02)

If your claim transaction was rejected due to a DUR conflict and you intend to dispense the drug, you will need to override the conflict (if appropriate). In order to process a DUR override, the same code that was returned as the denial code (Drug Conflict Code) must be placed in the DUR Conflict Code field. The DUR Conflict Code being sent as the override must match the DUR Conflict Code received in the response of the original transaction. A corresponding entry must also be entered in the DUR Outcome Code field. The only conflict codes that are DUR denials and reject the claim are TD (severity level 1) and DD (severity level 1). All of the other codes being returned are warnings and allow your claim to be accepted. Any attempt to override a warning will be rejected. However, we have learned that some software packages are requiring you to do internal overrides for the warnings.

At this time the only rejects that can be overridden are:

TD = Therapeutic Duplication

DD = Drug to Drug Interaction

One of the following values must be used in the DUR Outcome Code for DUR reject overrides:

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

DUR Override Documentation

If a pharmacist overrides a rejected DUR conflict, it is recommended that:

a) The pharmacist writes the date, reason for override and his/her signature or initials on the back of the prescription.

b) If the software permits, comment and electronically store the reason for the override in the patient profile for the specific prescription filled.

5.0 Pro-DUR/ECCA Input Information (Rev. 11/02)

This section describes the input fields required by the New York State Pro-DUR/ECCA system. The way you see this information as you provide input is largely a factor of your computer's software. In fact, some of these field values may be entered on your behalf by your software.

The required transaction header information shown in this section is needed for each transaction request that is sent to the MEVS Pro-DUR/ECCA system.

The NCPDP field numbers are shown in parenthesis at the end of the description for each field.

Following is a description of the fields that must be submitted to the Pro-DUR/ECCA system for each transaction.

FIELD	DESCRIPTION
Bin Number	All requests must send 004740, which identifies the New York MEVS Pro-DUR/ECCA system. In most cases, this information is automatically provided by your computer software. (101)
Cardholder ID Number	The Cardholder ID Number is the eight position alpha numeric Medicaid Client Number (CIN) or the thirteen digit Access Number without the six digit ISO # prefix. Both of these values are provided on the recipient's benefit card. (302)
Category of Service	The 4 digit category of service assigned to your provider number that identifies DME or RX services is required if the item/NDC code requires a DVS number. Enter the COS in the last four positions of the pharmacy number field immediately after your MMIS provider ID. (201)
Date Filled	The Date Filled is the date the prescription was dispensed. The current date must be used for DVS transactions. (401)
Date of Birth	The Date of Birth is the date the recipient was born, including the century, which is provided on the recipient's benefit card. Format = CCYYMMDD (304)
Other Coverage Code	This field is used by the pharmacy to indicate whether or not the patient has other insurance coverage. (308) Valid entries are: 0 = Not Specified 1 = No Other Coverage Identified 2 = Other Coverage Exists, Payment Collected 3 = Other Coverage Exists, This Claim Not Covered. 4 = Other Coverage Exists, Payment Not Collected
Person Code	The Person Code is the Sequence Number found on the recipient's benefit card in the last 2 positions of the access number. (303)
Pharmacist's Initials	The Pharmacist's Initials entered in the Processor Control Number provides the first and last initial of the person submitting the claim. (104)
Pharmacy Number	The Pharmacy Number is an eight digit Medicaid Provider Identification Number assigned to the pharmacy by the Department of Health. (201)
PIN	The four digit PIN entered in the Processor Control Number is the Personal Identification Number previously selected by the provider and submitted to the Department of Health. (104)
Processor Control Number	Information entered in the Processor Control Number is used to indicate that you are requesting Electronic Claim Capture and Adjudication. The following fields are required by Pro-DUR/ECCA if you are requesting your claim(s) to be captured for adjudication by the eMedNY contractor. Read Certification Statement Indicator Pharmacist's Initials PIN TSN (104)
Read Certification	A (Y) entered in the Read Certification Indicator contained in the Processor Control Number indicates that you have read and attest to the agreements in the Certification Statement (see Form Section). An "N" indicates that you have not read the Certification Statement or that you do not agree. (104)
Sex Code	The sex code indicates the recipient's gender as follows: 1 = Male 2 = Female (305)
Specialty Code	A Specialty Code is normally not required, except to identify the type of service being provided as below: 307 = Durable Medical Equipment (DME) (201)
Transaction Code	This field identifies the type of transaction request and the number of prescriptions being submitted. Acceptable codes are: 00 = Eligibility Verification with no claim submitted 01 = 1 Rx Billing 02 = 2 Rx Billings 03 = 3 Rx Billings 04 = 4 Rx Billings For Durable Medical Equipment (DME) authorizations use 01. 11 = 1 Rx Reversal Used to cancel a previous transaction. Please see section on Reversals. 31 = 1 Rx Rebill 32 = 2 Rx Rebill 33 = 3 Rx Rebill 34 = 4 Rx Rebill Note that 31-34 are used to adjust a previously paid claim(s). 81 = 1 Rx DUR only 82 = 2 Rx DUR only 83 = 3 Rx DUR only 84 = 4 Rx DUR only 81-84 are used to supply DUR information only for purposes of updating a recipient's drug history file when no claim submission or reimbursement is allowed or expected. (103)
TSN	The 3 character Transmission Supplier Number entered in the Processor Control Number is assigned to the provider by the EMedNY contractor. (104)
Version/Release Number	This identifies the NCPDP version used for your transaction and is commonly provided by your computer software. Some information fields are not available in the Fixed Format. These exceptions will be noted as the fields are described. (102) 32 = Variable Format 3A = Fixed Format

5.1 Claim Information Fields (Rev. 11/02)

Following is a list of information that may be required to process a claim.

FIELD	DESCRIPTION
Alternate Product Code	The Alternate Product Code is used to enter the 5 digit alpha/numeric product supply code. The MMIS Provider Manual contains a list of the valid product supply codes (pg. 4-9 through 4-31). When entering an Alternate Product Code, the Alternate Product Type field entry must be a 1. When entering an Alternate Product Code, the NDC Code field must be all zeroes. This field should also be used for DVS transactions. Note that this field is not available for use in the NCPDP Fixed RTDS 3A format. (437)
Alternate Product Type	The Alternate Product Type is used to identify the Product Type dispensed. This field must contain a "1" when the item dispensed is a product supply item (pg. 4-9 through 4-31 of the MMIS Provider Manual), or for item codes requiring a DVS number which were published in a list. Please Note: This field is not available when using the NCPDP Fixed RTDS 3A format. (436)
Compound Code	The Compound Code identifies the type of prescription as follows: 0 = Not specified. Use for DVS transactions. 1 = Not a compound - use when dispensing a prescription drug with an 11 digit NDC code. 2 = Compound - use when dispensing a compound drug. ECCA is not allowed for compounds. Please Note: 0 or 1 may be used for sickroom supplies if you are using the NCPDP Variable format. If you are using the NCPDP Fixed format, you must use 0 for sickroom supplies. (406)
Date Prescription Written	The Date the Prescription was written is entered in this field. The Date Prescription Written must be no more than 60 days prior to the Date Filled for original scripts. For Refills, the Date Prescription Written cannot be over 180 days old from the Date Filled. (414)
Days Supply	The Days Supply is the estimated number of days that the prescription should last. New York State does not accept a days supply greater than 366. When the prescription's directions state "take as directed" (PRN), it is strongly advised that 180 be entered as the days supply. (405)
Dispense As Written (DAW)/Product Selection Code	Acceptable values for the Dispense As Written (DAW) code are as follows: 0 = No product selection 1 = Substitution not allowed by prescriber 4 = Substitution allowed - Generic Drug not in stock 5 = Substitution allowed - Brand Drug dispensed as a Generic 7 = Substitution not allowed - Brand Drug mandated by Law 8 = Substitution allowed - Generic Drug not available in the Marketplace (408)
DUR Conflict Code	The DUR Conflict Code is used to indicate an override for a DUR reject of a previously entered claim. Acceptable values are: TD = Therapeutic Duplication DD = Drug to Drug Interaction (439)
DUR Outcome Code	The DUR Outcome Code is used to indicate the action taken by the pharmacist, and is required for a DUR override. Acceptable values are: 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 (441)
Eligibility Clarification Code	The Eligibility Clarification Code is used to indicate an eligibility override for Excess Income/Spenddown recipients when the spenddown has been met but eligibility has not been updated on file. Recognized value is: 2 = Override Note that this is the only value used to override eligibility by NYSDOH and can only be used for spenddown claims. Any other NCPDP allowable values entered in this field will be ignored. Refer to Section 2.13 for additional information on this field. (309)
Metric Quantity	The Metric Quantity is the total number of Metric Units dispensed for the prescription. New York State cannot accept a quantity greater than 9,999. (404)
NDC Number	The NDC Number is the 11 digit National Drug Code identifying the dispensed drug. For compound drugs, use the following values: Legend: 99999999999 Schedule II: 99999999992 Schedule III: 99999999993 Schedule IV: 99999999994 Schedule V: 99999999995 Compounds: 99999999996 (407)
New/Refill Code	The New/Refill Code values are as follows: 00 = New Prescription 01 = First Refill 02 = Second Refill 03 = Third Refill 04 = Fourth Refill 05 = Fifth Refill The maximum number of refills allowed is 5. This value cannot be greater than the Number of Refills Authorized (403)
Number of Refills Authorized	The Number of Refills Authorized is entered in this field. New York State only allows a maximum of 5 refills. (415)
Other Payor Amount	This field is used by the pharmacy to enter the dollar amount received from a recipient's other third party insurance company. Note: If other third party coverage exists but the claim being submitted is not covered, enter zeroes in this field. Refer to the chart in Section 2.5 for information on the proper completion of this field. This field is not available for use in the NCPDP Fixed RTDS-3A format. (431)
Patient Paid Amount	This field is used by the pharmacy to enter the dollar amount collected as a spenddown from an excess income recipient. Note: If the spenddown was previously met but the eligibility file has not yet been updated, enter zeroes in this field. Refer to Section 2.13 for additional information on this field. (433)
Pharmacist's Identification	The Pharmacist's Identification may be entered on claims in place of the pharmacist's initials found in the Processor Control Number field. If used, the first two positions must contain the first and last initial of the pharmacist's name. (444)
Prescriber ID	The Prescriber ID is the Ordering Provider who wrote the prescription. Either the ordering provider's MMIS Provider ID number or license type and license number must be entered. Refer to MEVS Denial code 056 in Table 2 for further clarification. (411)
Prescription Denial Clarification	The Prescription Denial Clarification is used to indicate a Utilization Threshold override and replaces the use of the SA Exception Code. Following are the recognized values: 00 = Not Specified 01 = No Override 02 = Other Override - use to replace SA Exception Code P (pending an override) 07 = Medically Necessary - use to replace SA Exception Code J (Immediate Urgent Care) & L (Emergency). Note that these are the only values used for UT Override by NYSDOH when using the NCPDP format. Any other value entered in this field will be ignored. (420)
Prescription Number	The Prescription Number is assigned by the pharmacy. (402)
Primary Prescriber	The Primary Prescriber is used to enter the 8 digit MMIS Provider ID Number of the primary provider to which the recipient is restricted. This field must be completed for a restricted recipient unless you are the primary provider or the primary provider is indicated as the prescriber in field 411. (421)
Prior Authorization/ Medical Certification	The Prior Authorization/Medical Certification Code and Number is used to enter a prior approval number. The format for this field is: 1 followed by the 8 digit prior approval number and then three zeroes or co-pay exemptions. Refer to Section 2.11 for additional information on this field. (416)
Usual and Customary Charge	The Usual and Customary Charge is used to enter the amount charged for the prescription. (426)

FIELD	DESCRIPTION
Response Status (Header)	An A (Accepted) will be returned if the information in the header is valid. An R (Rejected) will be returned if the information in the header is invalid. Further clarification of the reject will be indicated by NCPDP Reject codes and in the Message Area. Please Note: When an R is returned in the Header Response Status, all of the claims submitted on this request transaction will be rejected. (501)

Following is a description of the information that will be returned from Pro-DUR/ECCA for each claim sent. Please Note: The following field descriptions are in alphabetical order and not necessarily the order in which they appear in the response.

FIELD	DESCRIPTION
Additional Message	The Additional message area, in the NCPDP format, is used to return additional MEVS information about your request transaction. Your system may separate this information to clearly identify the contents of this additional message. However, some systems may display this message as it is returned in the NCPDP format. Please refer to Chart B for an example of the Additional Message. The following information is returned in the Additional Message: Medicare Coverage HIC Number Insurance Carrier Codes Insurance Coverage Codes Indication of Additional Coverage Restriction Information - Exception Codes Dispensing Validation System Number (526)
Amount of Copay/ Coinsurance	The amount of co-pay due for the entered NDC or APC (NY Product Supply Code) will be returned in the Amount of Copay/Coinsurance if the recipient has not met their co-pay or is exempt. (518)
Anniversary Month	The Anniversary Month found in the Message Text is the month of the recipient's Medicaid eligibility recertification. (504)
Authorization Number	The authorization number is the 9 digit invoice number returned if ECCA was requested and all edits were passed. This is the invoice number that will appear on your remittance statement from the eMedNY contractor. Please Note: NO CLAIM TO FA will be returned if the claim is captured but cannot be processed for adjudication. Below are a few examples of when this will occur: • Original claims over 90 days old. • Some third party claims • Processor Control Number blank or missing • Compound drug claims If a claim is captured but cannot be processed for adjudication, it must be billed via paper or magnetic media. (503)
Category of Assistance	Category of Assistance Code returned within the Message Text: S = SSI * = No valid category of assistance is available (504)
Claim Response Status	This is the status for each claim that was submitted. A "C" indicates that the claim is accepted and/or pending, and an "R" indicates that it is rejected. A separate Claim Response Status will be received for each claim submitted on your request (1 - 4). Refer to the Reject Codes, the MEVS Denial Code, the Rx Denial Code, the Utilization Threshold/Post & Clear Code, and the Dispensing Validation Reason Code to determine why an "R" is returned in the Claim Response Status. If a "C" is returned, the Authorization Number field must be checked to determine if the claim has been electronically captured for adjudication. The MEVS Pend Response Code Table should also be checked to see if the claim is pending. (501)
Clinical Significance	Clinical Significance returned within the DUR Response Data indicates how critical the conflict is. This value reflects the severity level assigned to a contraindication. See DUR Processing Section for a list of clinical significance codes and their meanings. (528)
Co-Payment Code	The Co-Payment Code returned within the Message Text provides the status of co-payment for this claim. (504)
Co-Payment Met Date	The Co-Payment Met Date returned within the Message Text identifies the date the recipient has met this year's co-payment requirement. (504)
County Code	The two-digit code for the county of fiscal responsibility for the recipient is provided within the Message Text. Refer to the list of county codes in the Codes section of the MEVS Provider Manual. (504)
Database Indicator	The Database Indicator returned within the DUR Response Data is always 1 to indicate that First DataBank is the source of the DUR database. (532)
Dispensing Validation

1.0 INTRODUCTION (Rev. 11/02)

2.0 GENERAL INFORMATION (Rev. 11/02)

2.1 Access Methods (Rev. 11/02)

2.2 Card Swipe (Rev. 11/02)

2.3 Response Formats (Rev. 11/02)

2.4 Electronic Claims Capture and Adjudication (ECCA) (Rev. 11/02)

2.5 Third Party Claims (Rev. 11/02)

Chart 1 – Recipient with Coverage Codes H, K, M, O or ALL on file

Chart 2 - Recipient without Coverage Codes on file

2.6 Rebills/Adjustment Information (Rev. 11/02)

2.7 Refills Information (Rev. 11/02)

2.8 Alternate Product Codes (Rev. 04/03)

2.9 APC Quantities (Rev. 11/02)

Enteral Products

2.10 Dispensing Validation System (Rev. 04/03)

2.11 Prior Authorization/MC Code and Number - Field 416 (Rev. 11/02)

2.12 Temporary Medicaid Authorizations (Rev. 11/02)

2.13 Excess Income/Spenddown Claims (Rev. 11/02)

2.14 Duplicate Claim Transactions (Rev. 11/02)

3.0 Pro-DUR PROCESSING (Rev. 11/02)

3.1 DUR Response Fields (Rev. 11/02)

Drug Conflict Code

Clinical Significance

Other Pharmacy Indicator

Previous Date of Fill

Quantity of Previous Fill

Database Indicator

Other Prescriber Indicator

Conflict Code Free Text Descriptions

4.0 OVERRIDE PROCESSING (Rev. 11/02)

4.1 DUR Override (Rev. 11/02)

4.2 Utilization Threshold (UT) Override (Rev. 11/02)

5.0 Pro-DUR/ECCA Input Information (Rev. 11/02)

5.1 Claim Information Fields (Rev. 11/02)

DESCRIPTION

6.0 PRO-DUR/ECCA RESPONSE MESSAGES (Rev. 04/03)

DESCRIPTION