STATE OF NEW YORK

DEPARTMENT OF HEALTH

eMedNY

Prospective Drug Utilization Review/

Electronic Claims Capture and Adjudication

ProDUR/ECCA Provider Manual

TABLE OF CONTENTS

Section

1.0 INTRODUCTION 1.0.1

2.0 GENERAL INFORMATION 2.0.1

2.1 Access Methods. 2.1.1

2.2 Card Swipe. 2.2.1

2.3 Response Formats 2.3.1

2.4 Electronic Claims Capture and Adjudication (ECCA) 2.4.1

2.5 Medicare and Third Party Claims 2.5.1

Chart 1 – Recipient with Coverage Codes H, K, M, O or ALL on file. 2.5.3

Chart 2 - Recipient without Coverage Codes on file. 2.5.4

2.6 Rebills/Adjustment Information. 2.6.1

2.7 Refills Information 2.7.1

2.8 Health Care Financing Administration Common Procedure Coding System (HCPCS) 2.8.1

2.9 HCPCS Quantities 2.9.1

2.10 Dispensing Validation System 2.10.1

2.11 Prior Auth Type Code and Prior Auth Number Submitted. 2.11.1

2.12 Temporary Medicaid Authorizations. 2.12.1

2.13 Excess Income/Spenddown Claims 2.13.1

2.14 Duplicate Claim Transactions 2.14.1

3.0 Pro-DUR PROCESSING 3.0.1

3.1 DUR Response Fields 3.1.1

Reason For Service (Conflict Code) 3.1.1

Clinical Significance. 3.1.1

Other Pharmacy Indicator (529-FT) 3.1.3

Previous Date of Fill (530-FU) 3.1.3

Quantity of Previous Fill (531-FV) 3.1.3

Database Indicator (532-FW) 3.1.3

Other Prescriber Indicator (533-FX) 3.1.3

Conflict Code Free Text Descriptions. 3.1.4

4.0 OVERRIDE PROCESSING 4.0.1

4.1 DUR Override 4.0.1

4.2 Utilization Threshold (UT) Override 4.2.1

5.0 Pro-DUR/ECCA Input Information 5.0.1

5.1 Header Information Fields 5.0.1

5.2 Claim Information Fields 5.2.1

6.0 PRO-DUR/ECCA RESPONSE MESSAGES 6.0.1

7.0 PRO-DUR/ECCA REVERSAL/CANCEL TRANSACTIONS 7.0.1

8.0 MESSAGE CHARTS 8.0.1

9.0 MEVS ACCEPTED CODES - TABLE 1 9.0.1

10.0 MEVS DENIAL CODES - TABLE 2 10.0.1

11.0 CO-PAYMENT CODES - TABLE 6 11.0.1

12.0 Rx DENIAL CODES - TABLE 7 12.0.1

13.0 PHARMACY UT/P & C CODES - TABLE 8 13.0.1

14.0 DISPENSING VALIDATION SYSTEM REASON CODES - TABLE 9 14.0.1

15.0 PEND REASON CODES – TABLE 10 15.0.1

16.0 NCPDP REJECT CODES 16.0.1

17.0 GLOSSARY OF ABBREVIATIONS AND TERMS 17.0.1

18.0 QUESTIONS AND ANSWERS 18.0.1

19.0 FORMS 19.0.1

Personal Identification Number Request 19.0.2

Certification Statement For Provider Utilizing Electronic Billing. 19.0.3

1.0 INTRODUCTION (Rev. 11/03)

The New York State Department of Health (DOH) has implemented a program that allows the pharmacy community to submit MEVS transactions in an online real-time environment that performs a Prospective Drug Utilization Review (Pro-DUR). This program was implemented on June 1, 1994 and is currently being administered by the eMedNY contractor. In order to receive payment for services rendered, all pharmacies must submit their transactions through the online ProDUR system. An optional feature of the ProDUR program is the Electronic Claim Capture and Adjudication (ECCA) of claims by the eMedNY contractor. The purpose of the Pro-DUR program is to be in compliance with OBRA 90 mandated Pro-DUR requirements. This program will check all prescriptions with prescription drugs the recipient has taken over the past 90 days and alert the pharmacists to possible medical problems associated with dispensing the new drug.

The telecommunication standards for the Pro-DUR/ECCA system are the same as those recommended by the National Council for Prescription Drug Program, Inc. (NCPDP) and named under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Only the NCPDP 5.1 Telecommunications standard and the 1.1 Batch formats are supported. The New York State format specifications were developed by using the Official Release of the NCPDP Version 5 Release 1 standard and the 1.1 Batch standard. The NCPDP Official Release is available to NCPDP members from the following address:

National Council for Prescription Drug Programs Inc.

9240 East Raintree Drive

Scottsdale, AZ 85260

(480) 477-1000

2.0 GENERAL INFORMATION (Rev. 11/03)

The mandatory Pro-DUR/ECCA program was implemented June 1, 1994 and is currently being administered by the eMedNY contractor. In order to receive payment for services rendered, all pharmacies must submit their transactions through the online Pro-DUR program using the NCPDP transaction format. Each pharmacy must choose an access method for these transactions. It is also each pharmacy's decision as to whether the transactions go directly to the eMedNY contractor or through a switch company, which in turn sends the transactions to the eMedNY contractor for processing.

Each online claim transaction is processed through the eligibility edits first, then through the Utilization Threshold (UT), Post and Clear (P&C), DUR, and Dispensing Validation System processing, if warranted. An accepted transaction gives you all the necessary UT, P&C and DUR authorizations in addition to recipient eligibility information. There is no need to do an eligibility or UT service authorization inquiry on the Verifone Omni 3750 Terminal or via telephone.

If you are already processing your transactions online, you should not be sending the same transaction through the Verifone Omni 3750 Terminal (transaction 1). This causes two service authorizations to be issued and increases the UT counts for the recipient. A recipient could reach his/her UT limit in error if double service authorizations were posted.

The Pro-DUR/ECCA online system is an adjudication system. The dollar amount returned in the online response is not the amount that you will be paid. It is the maximum reimbursable unit price amount.

The online system was designed to allow for capture and adjudication of the electronic submission. It is each pharmacy's option as to whether the claim data should be immediately captured online by the eMedNY contractor for payment or if the actual claim will be sent by the provider using paper, magnetic media or electronically, via Batch Pharmacy Dial-Up.

2.1 Access Methods (Rev. 02/04)

There are three potential access methods for submission of claims through the DUR system:

· PC to host - your Personal Computer will directly dial the MEVS host.

· CPU to CPU - your computer system has a dedicated communication line directly into the MEVS host processor.

· CPU to CPU through a switching company - your Personal Computer will access the MEVS host through a switching company. This access could be through dial up or leased line. The switching company will have a direct line into the MEVS host processor.

Providers must select one of the alternate access methods. If they choose not to use a switching company, they must become certified with the eMedNY contractor to verify their ability to access and process within the MEVS system. Submission via PC-Host or CPU-CPU access (switch or direct) allows up to a maximum of four claims per transaction.

Note: Switching companies or software vendors may restrict claims per transaction to less than four.

Pharmacies selecting the PC-to-Host access method must call 1-800-343-9000 to request a contract and certification package. If choosing to access through a switch, pharmacies must notify the switch and the switch company must notify the eMedNY contractor of the pharmacy’s name and MMIS provider number.

Once a pharmacy has selected an alternate access method, they will receive communication protocol information from the eMedNY contractor or from their switching company. For more information on these access methods OR if you would like a copy of the Pro-DUR/ECCA Standards Manual please contact the Provider Services Department at 1-800-343-9000.

2.2 Card Swipe (Rev. 11/03)

The card swipe function will still be available on the Verifone Omni 3750 Terminal for pharmacy providers who are designated by NYSDOH Quality Assurance and Audit Office as card swipe providers. Designated pharmacies must swipe the recipient's card on the Verifone Omni 3750 Terminal using transaction type 5, prior to entering the online DUR transaction. No DATA should be entered on the Verifone Omni 3750 Terminal. The eMedNY contractor will match the transactions to ensure that a swipe was performed. Only transaction type 5 will register and match the swipe to the online DUR transaction. The swipe only has to be done once for each recipient per date of service, regardless of the number of prescriptions being filled that day for that particular recipient.

2.3 Response Formats (Rev. 11/03)

Responses will be returned via the same alternate access method as the input transaction. The response for each claim will either be accepted or rejected. If the claim is rejected, reject codes will be provided to identify the nature of the problem.

If the claim has passed all edits and is acceptable, a C (Captured) will be returned in the prescription (claim) response status code. Each prescription (claim) in the transaction will have a prescription response. If multiple claims are entered on one transaction, it is possible some will be "C" and some will be "R" (Reject). The presence of a "C" does not mean that the claim has been electronically captured for adjudication by the eMedNY contractor. Refer to the ECCA section, on page 2.4.1 for further information.

Reject codes may appear in one or more of the following fields: NCPDP Reject Codes will be returned in the Reject Code (511-FB) field. MEVS Accepted and Denial Codes listed in Table 1 (page 9.0.1) and Table 2 (page 10.0.1), Rx Denial codes listed in Table 7 (page 12.0.1), UT/PC Codes listed in Table 8 (page 13.0.1), DVS codes listed in Table 9 (page 14.0.1), and the Pend Reason Codes listed in Table 10 (page 15.0.1) will be returned in the Additional Message Info (526-FQ) field. If a claim is rejected, an NCPDP Reject Code will always be returned in the Reject Code (511-FB) field and may have a corresponding MEVS Code placed in the Additional Message Info (526-FQ) field to further clarify the error. Both fields should always be reviewed. The valid NCPDP and MEVS Codes can be found in the tables at the end of this manual.

DUR denials will be returned via the rejected response format and will be found in the DUR/PPS Segment data fields. DUR warnings can be returned in both the approved and rejected response formats. Each submitted claim could have three (3) possible DUR responses. If a claim has three denial responses and also has warnings, only the denials will be returned. Additional information on DUR Response Data can be found in the Pro-DUR Processing section.

Note: 5.1 NCPDP Eligibility transactions do not validate the Prescribing Provider's enrollment in the Medical Assistance Program. In addition, they do not verify the Referring Provider for managed care enrollees and clients that are restricted to certain Providers.

2.4 Electronic Claims Capture and Adjudication (ECCA) (Rev. 11/03)

The Electronic Claim Capture and Adjudication feature is optional. Providers may elect to have their online 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 an Electronic Transmitter Identification Number (ETIN) (a/k/a TSN or Transmission Supplier Number) on file with the eMedNY contractor. To obtain an ETIN, 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 ETIN. If you choose your own ETIN, you can select paper or tape remittance. Once the eMedNY contractor has assigned you an ETIN, 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 (104-A4) field. The required data is the Read Certification Statement, Pharmacist's Initials, PIN, and ETIN. Further details of all input fields are explained in the input data section of this manual.

If the Processor Control Number (104-A4) 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 (503-F3) 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 (104-A4) field is completed and an invoice number was not returned in the Authorization Number (503-F3) 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 the Authorization Number (503-F3) field assigned online do not have to be submitted on paper, magnetic media or electronic batch. 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, magnetic media or electronic Batch Pharmacy Dial-Up.

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, magnetic media or Batch Pharmacy Dial-Up with the appropriate over ninety day reason indicated. Rebills and reversals are allowed to be submitted ECCA with service dates up to two years old.

2. Durable Medical Equipment (DME) claims. DME includes any claim identified by Specialty Code 307. Please Note: DME does NOT include the product supply codes (1 alpha, 4 numeric) found in the MMIS Pharmacy Provider Manual in sections 4.2 and 4.3. Pharmacy DME Claims must be submitted using 837 Professional ASC X12N.

2.5 Medicare and Third Party Claims (Rev. 02/04)

Third Party

A recipient's other insurance information (if any) is returned to you in the online 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 5.1 format, the Other Coverage Code (308-C8) field and Other Payer Amount Paid (431-DV) field must be entered. Refer to the ProDUR standards for exact formatting of the COB segment. 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 Payer Amount Paid (431-DV) field. The entry in each field must correlate to the other field and be logically correct for your claim to be accepted.

Note: The Other Payer Amount Paid 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.

The values for field 308-C8 (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

5 = Managed Care Plan – Denial

6 = Other Coverage Denied – Not Participating Provider

7 = Other Coverage – Not in Effect at Time of Service

8 = Claim is Billing for Copay

Note: Codes 5 & 6 will be processed as 3.

Code 7 will be processed as 1.

Code 8 will be processed as 2.

There are several edits in place to ensure that logical entries are made in both field 308-C8 and 431-DV. 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 (page 2.5.2) will occur when the recipient has MEVS Insurance Coverage Codes H, K, M, O or ALL on file with the eMedNY contractor. Chart 2 (page 2.5.3) will occur when no MEVS Insurance Coverage Codes indicating Pharmacy coverage for the recipient are on file.

Medicare

A client’s Medicare information (if any) is returned to you in the online response via the Additional Message field. If Medicare covers the NDC/HCPCS code being dispensed, a claim must be submitted to Medicare first.

For a Medicare Crossover claim to be successfully captured for ECCA via the variable 5.1 format, the appropriate Medicare fields must be entered. Refer to the ProDUR Standards for exact formatting of the COB Segment. The entry in each Medicare field must correlate to the entry in the other Medicare fields and be logically correct for your claim to be accepted.

Note: The Medicare fields are optional fields and should not be submitted unless you have received reimbursement from Medicare.

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

Field 308-C8 Value	Field 431-DV Value	NCPDP Format Version	Field 104-A4 Value	Claim Status
0, 1, 2, 3, 4, 5, 6, 7, 8	431-DV is Not sent	51	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 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
0, 1, 4 or 7	Zeros or greater	51	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 online.
2 or 8	Zeros	51	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 or 8	Greater than Zero	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned). Other payor amount will be subtracted from the claim’s payment amount.
2 or 8	Greater than Zero	51	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 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
3, 5 or 6	Zeros, blank or not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
3, 5 or 6	Zeros	51	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 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
3, 5 or 6	Greater than Zero	51	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-C8 Value	Field 431-DV Value	NCPDP Format Version	Field 104-A4 Value	Claim Status
0, 1, 2, 3, 5, 6, 7 or 8	Not sent	51	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 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
0, 1 or 7	Not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
0, 1, 3, 5, 6 or 7	Zeros	51	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 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
0, 1, 7	Zeros	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
3, 5 or 6	Zeros, blank or not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
0, 1, 3, 4, 5, 6 or 7	Greater than Zero	51	Non-ECCA or ECCA	The transaction will be rejected. NCPDP Reject Code “DV - M/I Other Payor Amount Paid” and Response Code “320 – Other Insurance Information Inconsistent” will be returned.
2, 3, 5, 6, or 8	Not sent	51	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 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
4	Not sent or zeros	51	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 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
2 or 8	Greater than Zero	51	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 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
2 or 8	Greater than Zero	51	ECCA	If all other edits are passed, the transaction will be accepted for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
2 or 8	Zeros	51	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. 11/03)

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 Code (103-A3) field value B3 and a Transaction Count (109-A9) field of 1 through 4. The number of claim lines contained within the transaction is indicated by the Transaction Count (109-A9) field. (If one claim line is contained in the transaction, the Transaction Count should be 1. If four claim lines are contained in the transaction, the Transaction Count should be 4).

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, Cardholder ID, 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 where you can supply the Claim Reference Number of a specific claim you are trying to adjust.

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, magnetic media and electronic batch 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 cannot 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, magnetic media or electronic batch. You may also reverse the original claim and then submit another original transaction with the corrected information.

2.7 Refills Information (Rev. 11/03)

The New York State Department of Health (NYSDOH) only allows a maximum of five (5) refills on a prescription. All of the refills must be dispensed within 180 days from the date the prescription was written. Claims for refills over 180 days from the date the prescription was written will be rejected.

The New York State DUR Board has established a standard that if a refill is dispensed too early, you will receive a TD WARNING – EARLY REFILL MMDDYY warning in your DUR response. Please note that the TD WARNING – EARLY REFILL MMDDYY response is only a warning, not a DUR denial (reject).

2.8 Health Care Financing Administration Common Procedure Coding System (HCPCS) (Rev. 11/03)

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 in sections 4.2 and 4.3 of the MMIS Pharmacy Provider Manual. For DVS, DME items are only reimbursable under COS 0442. The transaction must be sent through ePACES, Verifone Omni 3750 Terminal or 278 ASC X12N.

The 5 digit alpha-numeric codes must be submitted in the Product/Service Id (407-D7) field along with the Product/Service Id Qualifier (436-E1) field, which identifies the number being sent. A qualifier of ‘09’ must be used in the NCPDP 5.1 format. If the code and the qualifier are not submitted in these fields, your claim will be rejected.

When submitting HCPCS codes, ensure that the following fields are correctly completed:

FIELD	CONTENTS
Compound Code	Must contain a zero or one. Use zero for DVS transactions.
Product/Service Id Qualifier	Must contain a value of ’09’.
Product/Service Id	HCPCS 5 characters in length plus 2 blanks

A correct entry in the Product/Service Id field would look as follows:

Z2500bb

Note: Where bb equal two blanks or BO modifier.

Z2500BO

When submitting HCPCS if a modifier is required, append to the HCPCS code.

2.9 HCPCS Quantities (Rev. 11/03)

Be aware that the Quantity/Size listed in the MMIS Provider Manual for each HCPCS code is not usually the quantity that should be entered in the Quantity Dispensed (442-E7) 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 Quantity Dispensed (442-E7) field should be the number of units dispensed.

The following examples are listed to help clarify the correct Quantity Dispensed (442-E7) field entries.

HCPCS		QUANTITY SIZE IN MANUAL	QUANTITY DISPENSED	MAX QUANTITY
Code	Description
Z2001	Butterfly Clamps	100's (up to 1)	0000001000 (1 box dispensed)	1 box
Z2003	Plastic Strips	50's	0000002000 (2 boxes of 50 dispensed)	5 boxes
Z2012	Adhesive Tape	2" x 5 yd	0000003000 (3 rolls dispensed)	5 rolls
A4244	Alcohol or peroxide per pint	16oz	0000001000 (1 pint bottle dispensed)	5 bottles
A4215	Needles	each (up to 200)	0000056000 (56 needles dispensed)	200 needles
A4635	Underarm pad crutch replacement	each (up to 2)	0000001000 (1 pad dispensed)	2 pads

Note: Decimals are implied in the Quantity Dispensed field.

Enteral Products

The Quantity Dispensed (442-E7) field 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 75000. Do not include refills.

Note: The Quantity Dispensed (442-E7) is a 10 digit field with 7 digits to the left of the decimal and 3 digits to the right.

2.10 Dispensing Validation System (Rev. 11/03)

This function enables suppliers of 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 5.1 format. 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 the Additional Message (526-FQ) field 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), cannot be submitted through the NCPDP 5.1 format. The DVS Prior Approval must be requested through the Verifone Omni 3750 Terminal or 278 ASC X12N transaction. The claim must be billed using 837 Professional ASC X12N or paper Claim Form C. Be sure to put the DVS number on the claim.

Important Information Regarding DVS Transactions

· Transactions for both NDC’s and HCPCS can be submitted using the 5.1 format, if reimbursable under COS 0441, 0161 or 0288.

· Although multiple claim lines per transaction 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.

· 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.

2.11 Prior Auth Type Code and Prior Auth Number Submitted (Rev. 11/03)

The Prior Auth Type Code (461-EU) field is a two (2) position numeric field. There are two values expected by NYSDOH for this field.

01 = Prior Authorization. If this value is used, then Prior Auth Number Submitted (462-EV) field must contain in the first eight positions, a prior approval number followed by zeros to fill the field to eleven.

04 = Exemption from co-pay. Use to indicate the recipient is exempt. If this value is used, the eleven position numeric 462-EV field is submitted unless a previously obtained Prior Approval is being reported on the claim and the recipient is also exempt from co-pay.

The Prior Auth Number Submitted (462-EV) field is an eleven (11) position numeric field. If reporting a prior authorization, use a value (01) in 461-EU field. Send the prior authorization number in the first eight positions and fill the last three

positions with zeros.

If the patient is exempt from co-pay, submit a value (04) in 461-EU field.

Do not send Prior Auth Number Submitted (462-EV) field unless the claim also requires a

prior authorization.

2.12 Temporary Medicaid Authorizations (Rev. 11/03)

There have been increasing concerns regarding Medicaid provider acceptance of the Temporary Medicaid Authorization (DSS-2831A), especially from pharmacy providers. When an applicant is determined eligible and has an immediate medical need, the local district may issue a Temporary Medicaid Authorization pending the client receipt of a permanent Common Benefit Identification Card.

Please be aware that a mechanism is in place to reimburse providers for rendering services to a client with a Temporary Medicaid Authorization. Providers should first make a copy of all Temporary Medicaid Authorizations for their records. These claims cannot be submitted by pharmacies through the online Pro-DUR/ECCA program because eligibility is not yet on the files and may not have been determined yet. Pharmacy providers must put the letter "M" in the Service Authorization Exception field and submit the claim directly to the eMedNY contractor via paper. The claim will pay upon the local district verifying eligibility in WMS. If the claim pends for client ineligibility, wait for the final adjudication of the claim. This information will appear on your remittance statement. If the final adjudication of the claim results in a denial for client ineligibility, please contact NYS DOH, OMM Local District Support Unit. For Upstate recipients call (518) 474-8216; the number for New York City recipients is (212) 268-6855.

2.13 Excess Income/Spenddown Claims (Rev. 01/04)

Unlike the Temporary Medicaid Authorizations mentioned on the preceding page, these claims can be submitted through the online Pro-DUR/ECCA program. To properly submit a spenddown claim, the Eligibility Clarification Code (309-C9) field must contain a value of two (2) and the Patient Paid Amount (433-DX) field should contain the amount of the spenddown paid by the recipient, even if that amount is zero. These claims will not be processed through the eligibility edits. If the claim passes all other editing and you have elected the ECCA option, your claim will be captured and pended by the eMedNY contractor waiting for the WMS eligibility file update from the local district to indicate that the spenddown has been met. If the eligibility information does not appear in a timely manner on the eMedNY contractor file, the claim will be denied.

The Eligibility Clarification Code (309-C9) field may also be used to report a Nursing Home Override in those instances where the Client’s file shows residency within an In-State Skilled Nursing Facility that covers pharmacy services. The override procedure may be used to resubmit a previously denied claim. If the Client has been discharged but the eMedNY Contractors’ file shows that the Client still resides in the Skilled Nursing Facility, you may submit an override. This will result in a pend status which will give the local districts time to update the Client’s file. If the update is not received within 30 days, the claim will deny.

2.14 Duplicate Claim Transactions (Rev. 11/03)

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 Transaction Response Status (112-AN) field. 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:

· Service Provider Number (201-B1 on Transaction Header Segment)

· Cardholder ID Number (302-C2 on Insurance Segment)

· Date of Service (401-D1 on Transaction Header Segment)

· Prescription/Service Reference # (402-D2 on Claim Segment)

· Fill Number (403-D3 on Claim Segment)

· Prior Auth Number Submitted (462-EV on Claim Segment)

· Product/Service ID (407-D7)

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 Prior Auth Number Submitted (462-EV) field 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 Service Provider Number, Cardholder ID, and Prior Approval Number fields match a previous paid claim and one of the following conditions also exists:

· Prescription Service Reference Number matches, but NDC/HCPCS is different.

· NDC/HCPCS matches, but Prescription Service Reference Number is different.

· Prescription Service Reference Number and Fill Number is the same, but the Date of Service 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. 11/03)

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 Table 2 (page 10.0.1), Table 7 (page 12.0.1), Table 8 (page 13.0.1) and Table 9 (page 14.0.1).

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.

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.

3.1 DUR Response Fields (Rev. 11/03)

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

Drug Conflict Code (439-E4)

Clinical Significance (528-FS)

Other Pharmacy Indicator (529-FT)

Previous Date of Fill (530-FU)

Quantity of Previous Fill (531-FV)

Database Indicator (532-FW)

Other Prescriber Indicator (533-FX)

Free Text (544-FY)

Reason For Service (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

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.

Other Pharmacy Indicator (529-FT)

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

0 = Not Specified

1 = Your Pharmacy

3 = Other Pharmacy

Previous Date of Fill (530-FU)

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

Quantity of Previous Fill (531-FV)

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

Database Indicator (532-FW)

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 (533-FX)

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:

Note: Bold Text in the examples below represents 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			0000030000			1			1			PROPRANOLOL							10MG	TABLET 030
	For Clinical Significance 2 the words WARNING - EARLY REFILL MMDDYY
	Example
	TD	2			1			20020929			0000030000			1			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			0000030000			1			1			INF DIGITALIS/KALURETICS
	DEF Decreased effect of former drug
	Example
	DD	2			1	20021012			0000030000			1			1		DEF						CORTICOSTEROIDS/BARBITURAT
	INL Increased effect of latter drug
	Example
	DD	3			1			20021003			0000030000			1			1	INL						VERAPAMIL/DIGOXIN
	DEL Decreased effect of latter drug
	Example
	DD	2			1			20020920			0000060000			1			1	DEL						NSAID/LOOP DIURETICS
	ARF Adverse reaction of former drug
	Example
	DD	2			1			20021018			0000090000			1			1	ARF						THEOPHYLLINES/TICLOPIDINE
	ARL Adverse reaction of latter drug
	Example
	DD	1			1			20021014			0000050000			1			1	ARL						NSAID/TRIAMTERENE
	MAR Adverse reaction of both drugs
	Example
	DD	2			1			20020920			0000090000			1			1	MAR						ACE INHIBITORS/POTASS.SPAR
	MXF Mixed effects of former drug
	Example
	DD	2			1			20021018			0000015000			1			1	MXF						ANTICOAGULANTS,ORAL/ANTITH
	MXL Mixed effects of latter drug
	Example
	DD	2			1			20020919			0000060000			1			1	MXL						HYDANTOINS/DISOPYRAMIDE
DC	The description of the drug/disease contraindication.
	Example
	DC	1			1			20020914			0000090000			1			1				HYPERTENSION
PG	For pregnancy precautions the words PREGNANCY PRECAUTION
	Example
	PG	1			0			00000000			0000000000			1			0					PREGNANCY PRECAUTION
	For lactation precautions the words LACTATION PRECAUTION
	Example
	PG	2			0			00000000			0000000000			1			0					LACTATION PRECAUTION
PA	For pediatric precautions the word PEDIATRIC
	Example
	PA	1			0			00000000			0000000000			1			0					PEDIATRIC
	For geriatric precautions the word GERIATRIC
	Example
	PA	1			0			00000000			0000000000			1			0					GERIATRIC
LD	For low dose precautions the recommended minimum and maximum dosage will be shown.
	Example
	LD	1			0			00000000			0000000000						1							0	3.000			12.000
HD	For high dose precautions the recommended minimum and maximum dosage will be shown.
	Example
	HD	1			0			00000000			0000000000						1							0	1.000			8.00

4.0 OVERRIDE PROCESSING (Rev. 11/03)

4.1 DUR Override (Rev. 11/03)

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 Reason for Service Code (439-E4) 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 Result of Service Code (441-E6) 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 Result of Service 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.

OR

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

4.2 Utilization Threshold (UT) Override (Rev. 11/03)

If you receive a reject because a recipient is at their Utilization Threshold service limit (refer to message text field, UT/P&C codes DA, DD, or DN from Table 8 on page 13.0.1), and you intend to dispense the prescription, you will need to override the UT limit. To submit a UT override, the provider must resubmit the original transaction with an entry in the Submission Clarification Code (420-DK) field. This is the field that replaces the Service Authorization (SA) Exception Code field currently used for UT overrides when billing the eMedNY contractor on paper. If multiple claims are submitted in a single transaction, this field must contain the same value for each claim submitted.

Note: If a UT override is submitted and the recipient has not reached their UT limit, the transaction will be rejected. The following are the only acceptable values to be used in the Submission Clarification Code field if requesting a UT override.

02 = Other Override - use to replace SA Exception code P (Pending an override). If 02 is indicated a "Request for increase in UT Service Limit" must be submitted by the physician or other qualified practitioner.

07 = Medically Necessary - use to replace SA Exception Code J (Immediate Urgent Care) and L (Emergency).

5.0 Pro-DUR/ECCA Input Information (Rev. 11/03)

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.

5.1 Header Information Fields

The required 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-A1)
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-C2)
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-C4)
Date of Service	The Date Filled is the date the prescription was dispensed. The current date must be used for DVS transactions. (401-D1)
ETIN	The 3 character Electronic Transmitter Identification Number entered in the Processor Control Number is assigned to the provider by the EMedNY contractor. (104-A4)
Patient Gender Code	The patient gender code indicates the recipient's gender as follows: 1 = Male 2 = Female (305-C5)
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-C3)
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-A4)
Pharmacy Number	The Pharmacy Number is an eight digit Medicaid Provider Identification Number assigned to the pharmacy by the Department of Health. (201-B1)
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-A4)
Pregnancy Indicator	This code will specify whether the patient is pregnant. Valid values are: Blank = Not Specified 1 = Not pregnant 2 = Pregnant (335-2C)
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 ETIN (104-A4)
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 (refer to Form Section on page 19.0.1). An "N" indicates that you have not read the Certification Statement or that you do not agree. (104-A4)
Service Provider Id	This field must contain the NYS Medicaid Provider number assigned by NYSDOH (201-B1)
Service Provider Id Qualifier	This code will qualify the entry in the Service Provider Id field (201-B1) as an MMIS Provider ID number. Acceptable entry is: 05 = Medicaid (Must be submitted in conjunction with provider number assigned by NYSDOH) (202-B2)
Software Vendor/Certification ID	Mandatory field used to identify the software source by switches and/or processors. If not available or not used between trading partners, then submit 10 spaces. (110-AK)
Transaction Code	This field identifies the type of transaction request being submitted. Acceptable codes are: E1 = Eligibility Verification with no claim submitted B1 = Rx Billing P1 = P.A. Request and Billing P4 = Prior Authorization Request Only B2 = Rx Reversal B2 is used to cancel a previous transaction. Please refer to section on Reversals on page 7.0.1. B3 = Rx Rebill Note: B3 is used to adjust a previously paid claim(s). N1 = Rx DUR only N2 = Rx DUR Reversal N3 = Rx DUR Rebill N1 is 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-A3)
Transaction Count	This field identifies the number of prescriptions being submitted for a specific transaction. A number from 1 to a maximum of 4 is allowed dependent on the type of transaction. E1 = Eligibility (1 only) B1 = Billing submit from 1 to 4 B2 = Reversal submit 1 per transaction for NYS. If reversing a four (4) line transaction submit each line on a separate B2 transaction. B3 = Rebill submit from 1 to 4. P1 = Billing with P.A. Request submit only 1 P2 = P.A. Reversal submit only 1. P4 = P.A. Request Only submit only 1. N1 = DUR Info Report submit from 1 to 4. N2 = DUR Reversal submit 1 per transaction. N3 = DUR Rebill submit from 1 to 4. (109-A9)
Version/Release Number	This identifies the NCPDP version used for your transaction and is commonly provided by your computer software. 51 = Telecommunication Format (102-A2)

5.2 Claim Information (Rev. 04/04)

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

FIELD	DESCRIPTION
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. Please Note: 0 or 1 may be used for valid sickroom supplies if you are using the NCPDP 5.1 format. Refer to sections 4.2 and 4.3 in the MMIS Pharmacy Provider Manual. The 837 Professional ASC X12N MUST be used for sickroom supplies that are only billable under Category of Service 0442. (406-D6)
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-DE)
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-D5)
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-D8)
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. · To resubmit a previously denied claim when a Client is a Resident of an In-State Skilled Nursing Facility or Health Related Facility which includes coverage for pharmacy services. When the Client has been discharged and the records still reflect residency within the Facility, the claim may be incorrectly denied. An override may be submitted which will result in a pend status, giving the local district time to update the Client’s file. Recognized value is: 2 = Override (309-C9)
Fill Number	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-D3)
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-DF)
Other Coverage Code	This field is used by the pharmacy to indicate whether or not the patient has other insurance coverage. (308-C8) Valid entries NYSDOH are: 0 = Not Specified – Use for Medicare 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 The following codes if submitted will be cross-indexed as follows: 5 = Managed Care Plan – Denial is equated to 3 6 = Other Coverage Denied – Not Participating Provider is equated to 3 7 = Other Coverage – Not in Effect at Time of Service is equated to 1 8 = Claim is Billing for Co-pay is equated to 2 (308-C8)
Other Payor Amount Paid	For TPL: Enter the dollar amount of payments made by the other insurance. A maximum of 9 amounts can be submitted. 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 zeros or blanks in this field. You may also choose not to send this field if the primary carrier has denied the claim. Refer to the chart in Section 2.5 on page 2.5.1 for information on the proper completion of this field. (431-DV) For MEDICARE: Enter a series of dollar amounts with the appropriate qualifiers to identify the type of Medicare amount submitted. Refer to the Other Payer Amount Paid Qualifier (342-HC) below
Other Payer Amount Paid Qualifier	This code will qualify the other payer amount. Valid value for TPL reporting is: 07 = Drug Benefit (342-HC) This code will qualify the other payer amount. Valid values for Medicare COB (Coordination of Benefits) reporting are: 07 = Drug Benefit (used for Medicare Approved Amount) 08 = Sum All Reimbursements (used for Medicare Paid Amount) 99 = Other (1^st99 = Deductible Amount) 99 = Other (2^nd99 = Coinsurance Amount) 99 = Other (3^rd99 = Co-Payment Amount) (342-HC)
Other Payer ID	ID assigned to the payer when submitting electronically. For TPL, enter any valid value that identifies the Third Party Payer. ID assigned to the payer when submitting Medicare COB claims. For Medicare use: 13 = Medicare Part B. (340-7C)
Other Payer Date	Payment of denial Date of the claim being submitted for coordination of benefits. (443-E8)
Other Payer Amount Paid Count	Other payer amount paid count which is the count of other payer amount occurrences. (341-HB)
Other Payer ID Qualifier	Code qualifying the ‘Other Payer ID’. (340-7C) NYSDOH will process any valid value in conjunction with the Other Payer ID. Examples would be, but not limited to the following: 01 = National Payer ID