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
2.4 Electronic
Claims Capture and Adjudication (ECCA) 2.4.1
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
2.10 Dispensing
Validation System
2.11 Prior
Authorization/MC Code and Number - Field 416
2.12 Temporary
Medicaid Authorizations
2.13 Excess
Income/Spenddown Claims
2.14 Duplicate
Claim Transactions
Conflict Code
Free Text Descriptions
4.2 Utilization
Threshold (UT) Override
5.0 Pro-DUR/ECCA Input Information
6.0 PRO-DUR/ECCA RESPONSE MESSAGES
7.0 PRO-DUR/ECCA REVERSAL/CANCEL
TRANSACTIONS
9.0 MEVS ACCEPTED CODES - TABLE 1
10.0 MEVS DENIAL CODES - TABLE 2
11.0 CO-PAYMENT CODES - TABLE 6
12.0 Rx DENIAL CODES - TABLE 7
13.0 PHARMACY UT/P & C CODES - TABLE 8
14.0 DISPENSING VALIDATION SYSTEM REASON
CODES - TABLE 9
15.0 PEND REASON CODES – TABLE 10
17.0 GLOSSARY OF ABBREVIATIONS AND TERMS
Personal
Identification Number Request
Certification
Statement for Provider Utilizing Electronic Billing
The New York State Department of Health (NYSDOH) has implemented a program that allows the pharmacy community to submit MEVS transactions in an on-line 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 on-line 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 chosen for the Pro-DUR/ECCA system are the same as those recommended by the National Council for Prescription Drug Program, Inc. (NCPDP). Only the NCPDP variable format version 3.2 and the fixed RTDS-3A formats are supported. New York State format specifications were developed and approved by NCPDP using the February 11, 1992 Official Release of the NCPDP Version 3 Release 2 standard. The NCPDP Official Release is available to NCPDP members from the following address:
National Council for Prescription Drug Programs Inc.
4201 North 24th Street
Suite 365
Phoenix, AZ 85016-6268
(602) 957-9105
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 on-line 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 on-line 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 TRANZ 330 POS VeriFone Terminal or via telephone.
If you are already processing your transactions on-line, you should not be sending the same transaction through the POS 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 on-line system is an adjudication system. The dollar amount
returned in the on-line response is not the amount that you will be paid. It
is the maximum reimbursable unit price amount.
The on-line 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 by the eMedNY contractor for payment or if the actual claim will be sent by the provider using paper or magnetic media.
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 leased 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.
Special 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 Specifications please contact the Provider Services Department at 1-800-343-9000.
The card swipe function will still be available on the TRANZ 330 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 TRANZ 330 POS Verifone Terminal using transaction type 5, prior to entering the on-line DUR transaction. No DATA should be entered on the POS 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.
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 via the variable format, 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 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 field. MEVS Accepted and Denial Codes listed in Tables 1 and 2, Rx Denial codes listed in Table 7, UT/PC Codes listed in Table 8, DVS codes listed in Table 9, and the Pend Reason Codes listed in Table 10 will be returned in the Claim Message field. If a claim is rejected, an NCPDP Reject Code will always be returned in the Reject Code field and may have a corresponding MEVS Code placed in the Claim Message 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 Response Data field. 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.
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.
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.
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. |
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. |
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.
New York State 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).
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) |
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 |
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.
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.
This field is a twelve (12) position numeric field. There are two possible values for the first digit:
1 = Prior Authorization/Prior Approval. If this value is used, the next eight digits must contain the prior approval number.
4 = Exemption from co-pay. Use to indicate the recipient is exempt. If this value is used, the last three positions must contain a value to indicate the reason for the co-pay exemption. There are five possible values for the final three digits:
000 = No Co-pay Exemption
005 = Co-pay Exempt - Emergency
007 = Co-pay Exempt - Private Managed Care
008 = Co-pay Exempt - OMH Community Resident and/or Traumatic Brain Injury
009 = Co-pay Exempt - Pregnancy
If a claim requires prior approval and the recipient is also exempt from co-pay, use a value of one (1) in the first digit followed by the eight (8) digit PA number and the appropriate co-pay exempt value. If submitting a DVS transaction and the recipient is also exempt from co-pay, use a value of one (1) in the first digit followed by eight zeros and the appropriate co-pay exempt value.
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 on-line 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 or magnetic media. 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.
Unlike the Temporary Medicaid Authorizations mentioned on the preceding page, these claims can be submitted through the on-line Pro-DUR/ECCA program. To properly submit a spenddown claim, the Eligibility Clarification Code field must contain a value of two (2) and the Patient Paid Amount 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.
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.
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.
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
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)
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. |
The following values may be returned in the Other Pharmacy Indicator:
0 = Not Specified
1 = Your Pharmacy
3 = Other Pharmacy
The Previous Date of Fill provides the date the conflicting drug was dispensed.
The Quantity of Previous Fill provides the quantity of the conflicting drug.
The Database Indicator will always be returned with a value of 1 to indicate that First DataBank is the DUR database provider.
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
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. |
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.
OR
b) If the software permits, comment and electronically store the reason for the override in the patient profile for the specific prescription filled.
If you receive a reject because a recipient is at their Utilization Threshold service limit (see message text field, UT/P&C codes DA, DD, or DN from Table 8), 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 Prescription Denial Clarification 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 or magnetic media. If multiple claims are submitted in a single transaction, this field must contain the same value for each claim submitted. Please 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 Prescription Denial Clarification 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).
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 |
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) |
The information that is received from the New York State Department of Health Pro-DUR/ECCA system will vary depending upon whether the claim has been accepted or rejected. A separate response will be received for each claim submitted. For example, if three claims are submitted at a time, three responses will be returned from Pro-DUR/ECCA.
The NCPDP field numbers are shown in parenthesis at the end of the description for each field.
Following is a description of the information returned from Pro-DUR/ECCA for each request that is sent.
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 System Number |
The eight digit DVS Number (prior approval) will be returned in the Additional Message Text if the DVS
transaction is accepted. The number
will be automatically entered on your ECCA claim for adjudication
processing. If you did not submit the
claim for ECCA and are billing manually, this number must be put on your
claim form. (526) |
Dispensing Validation System Reason Code |
The three-digit code indicating either the accepted or rejected
status of the DVS request is returned within the Message Text. Refer to Table 9 for the codes and
descriptions. (504) |
Drug Conflict Code |
The Drug Conflict Code returned within the DUR Response Data will be generated and sent back to the pharmacy when a DUR conflict is detected. See DUR Processing section for further clarification. The following values may be returned. 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 (439) |
DUR Overflow |
DUR Overflow indicates whether there were more than three conflicts
found, and all could not be reported in the space provided in the NCPDP
response format. The DUR responses
are reported in order of severity.
The values are: 0 = Not specified 1 = No overflow 2 = Overflow (535) |
DUR Response Data |
Up to three DUR responses may be returned for each claim. Following
is a list of the information returned in the DUR Response Data: (525) Drug Conflict Code Clinical
Significance Other
Pharmacy Indicator Previous
Date of Fill Quantity
of Previous Fill Database
Indicator Other
Prescriber Indicator Free
Text For an example of the DUR Response Data please see Chart
D. |
Exception Codes |
Up to four Exception Codes may be returned within the Additional Message area. These codes indicate special eligibility
circumstances and can be found in the Codes section of the MEVS Provider
Manual. (526) |
Free Text |
The Free Text returned within the DUR Response Data contains information to assist the pharmacist
in further identifying the DUR conflict.
Please refer to the DUR Processing section.
(544) |
HIC Number |
The HIC Number returned within the Additional Message area is the Health Insurance Claim number for
Medicare. (526) |
Indication of Additional Coverage |
A ZZ in the Indication of Additional Coverage,
returned within Additional Message
area, indicates that the recipient has more than two insurance carriers. You must call the Provider Services
Department at 1-800-343-9000 to obtain complete information. (526) |
Insurance Carrier Codes |
Up to two Insurance Carrier Codes are returned within the Additional Message area to provide
the codes for insurance carriers. (Also, see Insurance Coverage Codes). (526) |
Insurance Coverage Codes |
Up to two sets of Insurance Coverage Codes are returned within the Additional Message area. These
correspond one for one to the Insurance
Carrier Codes and indicate the scope of benefits. Refer to the Codes section of the MEVS
Provider Manual for a description of the Insurance Coverage Codes. (526) |
Maximum Per Unit Price |
The Maximum Per Unit Price returned within the Message Text is the per unit amount on New York State’s Drug File. The price is the maximum reimbursable unit
price amount. The dollar amount returned to you in your response does not
indicate the amount of payment you will receive. (504) |
Medicaid Number |
The Client's Identification Number (CIN) is provided within the
Message
Text. (504) |
Medicare Coverage |
The Medicare Coverage code is returned within the Additional Message area and indicates
the type of Medicare coverage. A = Recipient has only Part A Medicare coverage (inpatient hospital). B = Recipient has only Part B Medicare coverage (outpatient). AB = Recipient has both Part A and Part B Medicare coverage. ABQMB = Recipient has Part A and Part B Medicare
coverage and is a Qualified Medicare Beneficiary (QMB). AQMB = Recipient has Part A Medicare coverage and is a Qualified
Medicare Beneficiary (QMB). BQMB = Recipient has Part B Medicare coverage and is a Qualified
Medicare Beneficiary (QMB). QMB = Recipient is a Qualified Medicare Beneficiary (QMB) Only. If a recipient’s eligibility code is 09 (Medicare
Coinsurance/Deductible), Medicaid will only reimburse for the Medicare
coinsurance/deductible if Medicare approves the drug or item being
dispensed. Since the majority of
drugs are not covered by Medicare, Medicaid would not be making
payment in most cases. Therefore, the
DUR system has been programmed to reject this type of claim (Table 2 code
105). In the rare case that Medicare
does approve the drug, the claim can be manually submitted to the eMedNY
contractor for payment. If the
recipient has full Medicaid coverage (coverage code 01) and is QMB,
the claim will not be rejected but will be captured and if ECCA was opted,
processed for adjudication. (526) |
MEVS Accepted Code |
The MEVS Accepted Code returned within the Message Text indicates the type of Medicaid eligibility the
recipient has. See Table 1 for a list of values and
meanings. (504) |
MEVS Denial Code |
The MEVS Denial Code returned within the Message Text indicates the type of MEVS error for rejected
transactions. See Table 2 for a list of values and
meanings. (504) |
DESCRIPTION |
|
A Message Text area returned in the NCPDP format is
used to provide MEVS information about your requested transaction. Your system may separate this information
to clearly identify the contents of this message. However, some systems may display this message as it is
returned in the NCPDP format. The
following information is returned in the Message field for accepted claims
(when Claim Response = C): Medicaid Number County Code MEVS Accepted or Pending Code Utilization Threshold/Post &
Clear Code Anniversary Month Sex Code Year of Birth Category of Assistance Re-certification Month Office Number Service Date Maximum Per Unit Price Co-Payment Code Co-Pay Met Date DVS Reason Code Please refer to Chart A for an example of the Message. (504) The following information is returned in the Message
field for rejected claims (when Claim
Response = R): MEVS Accepted, or Denial Code Rx Denial Code Utilization Threshold/Post &
Clear Code DVS Reason Code Please refer to Chart C for an
example of the Message. (504) |
|
Office Number |
The Office Number returned
within the Message Text represents the New York City
office code. Refer to the Codes
section
of the MEVS Provider Manual for a list of valid office codes. (504) |
Other Pharmacy Indicator |
The Other Pharmacy Indicator
returned within the DUR Response Data indicates the source of the previous prescription
that
forms the basis for the conflict with the present prescription. The following values may be returned. 0 = Not Specified 1 = Your Pharmacy 3 = Other Pharmacy (529) |
Other Prescriber Indicator |
The Other Prescriber Indicator returned within the DUR Response Data compares the Prescriber of the current prescription to the Prescriber of the previously filled conflicting prescription. The following values may be returned: 0 = Not Specified 1 = Same Prescriber 2 = Other Prescriber (533) |
Pend Reason Code |
The Pend Reason Code returned
within the Message Text indicates
that the claim has passed all other online adjudication edits but has been
pended for one of the reasons listed in Table 10. See Section
15.0 for values
and descriptions. The Table 10 reason
code will be returned in the same field positions that a Table 1 Accepted
Code is normally returned (Field 504, positions 34-36 in the variable format,
and positions 45-47 in the fixed format.)
Consequently, when the return of a Table 10 Pend Code is warranted, a
Table 1 Accepted Code will not be returned.
(504) |
Previous Date of Fill |
The Previous Date of Fill
returned within the DUR Response Data is the date that the previous prescription was
filled. (530) |
Quantity of Previous Fill |
The Quantity of Previous Fill
returned within the DUR Response Data is the quantity of the previously filled
prescription. (531) |
Recertification Month |
The Recertification Month
returned within the Message Text is
the
month the recipient is due for recertification. (504) |
Reject Codes |
A maximum of 20 Reject Codes
could be returned if the Claim Response Status is "R" (Reject). See NCPDP Reject Code list for values. (511) |
Rx Denial Code |
The Rx Denial Code returned
within the Message Text provides
prescription
related reject reasons. See Table 7 for
possible values.
(504) |
Service Date |
The Service Date returned
within the Message Text is the
same as the Date Filled (or dispensed), entered on your
transaction. (504) |
Sex Code |
Valid Sex Codes returned within the Message Text are: F - Female M - Male U - Unborn (504) |
Utilization
Threshold/ Post and Clear |
The Utilization Threshold/Post
& Clear codes indicate the status of the UT/P&C service authorization
requests. See Table 8 for
further clarification. (504) |
Year
of Birth |
The Year of Birth returned
within the Message Text shows the
century
and year of the recipient's birth.
Example: 1980 will appear as 980.
(504) |
This section describes the use of reversal transactions in the New York State Pro-DUR/ECCA system. A reversal transaction is used to cancel or reverse a previously submitted claim that was approved by the Pro-DUR/ECCA system. A reversal can now be used to void out a paid claim submitted via paper or magnetic media. Reversal transactions can be submitted online up to two years from the service date.
Reversal transactions can only cancel one claim at a time. For example, if four claims were submitted and approved on a single transaction request, four separate reversal transactions would be needed to cancel the entire transaction.
The primary matching values used to determine which claim is being canceled are the Provider Identification Number, Prescription Number, and Service Date, which were submitted on the original claim. If the reversal is approved, code 021 is returned in the MEVS Accepted Code. If no match is found for the reversal, code 045 (No Authorization Found) is returned in the MEVS Denial Code.
The following fields are required for a reversal transaction. Please see the Pro-DUR/ECCA Input Information section for a description of these fields.
BIN Number
Version/Release
Number
Transaction
Code (11)
Pharmacy
Number
Date
Filled
Prescription
Number
Processor
Control Number (if a paid claim is being reversed)
The following information is returned if the cancel is accepted.
Response Status (A)
Authorization Number (The invoice number of the original claim will be returned in the response.)
MEVS Response Code (021)
The following information is returned if the cancel was denied.
MEVS Denial Code (R)
Rx Denial Code
Reject Codes (up to 10)
NCPDP Reversals can be submitted for service dates up to two years old as long as the previous transaction (either ECCA, non-ECCA, or claims submitted via paper or magnetic media) was submitted directly to the eMedNY contractor, or the transaction was submitted to eFunds no longer than 90 days prior to the eMedNY contractor takeover of the MEVS system.
By submitting a reversal via NCPDP format, you can either: reverse a previous NCPDP transaction, or use the NCPDP reversal to void a claim sent via paper or magnetic media. If a non-capture transaction (NO CLAIM TO FA) is being reversed, the action taken by the claims processing system is contingent on if the subsequent paper or magnetic media claim was approved during the interim.
If a paper or magnetic media claim was approved for payment during the interim, the paper or magnetic media claim will be voided, and any units used by the claim will be restored to its applicable service authorization or prior approval. The service authorization and prior approval will remain available for future use until the record becomes inactive.
If a subsequent paper or magnetic media claim has not been approved for payment during the interim, the non-capture transaction will be reversed, and any applicable service authorization or DVS prior approval generated as a result of submitting the non-capture transaction will be cancelled. When cancelled, the authorizations and approvals previously generated are no longer useable.
When reversing a previously submitted ECCA transaction that was captured for payment, if approved, the reversal will cancel any service authorization or DVS prior approval generated by the original transaction.
If you need to reverse a previously paid
ECCA, paper, or magnetic media claim online, you must complete the processor
control number field on the reversal transaction. If omitted, your reversal
will be rejected for response code 323 (see Table
2 codes). If you need to reverse a non-ECCA claim, then you may choose to
forego entering your processor control number.
The following charts are used to illustrate various types of messages you can receive from your transactions. The charts are shown as to content of data. A single chart does not reflect the entire message you will receive in a single response.
All of the Table 1 codes (except 017 and 021) indicate the type of Medicaid eligibility for the recipient. If the recipient is Medicaid eligible, a Table 1 code will be returned on each claim transaction even if the transaction is rejected for other reasons. (i.e.: Utilization Threshold, DUR Denial, etc.). An exception to this is if the transaction is rejected for header field errors (Code 999 found in Table 2) and is not processed through the eligibility modules or an invalid Medicaid ID or sequence number is entered. Another exception is when a pend reason code from Table 10 is warranted in the response. Table 1 codes are eligibility codes. There are no existing comparable NCPDP codes that are returned with these codes.
Code 017 does not indicate Medicaid eligibility but denotes a recipient enrolled in the Family Health Plus Program.
Code 021 is not an eligibility status code. It is returned if your transaction to cancel a previously accepted claim has been accepted.
Code |
Description |
002 |
MA Eligible |
003 |
Eligible Only
Outpatient Care |
005 |
Eligible Capitation
Guarantee Only |
006 |
Eligible PCP |
007 |
Emergency Services Only |
008 |
Presumptive Eligible
Long-Term/Hospice |
009 |
Medicare Coinsurance
Deductible Only |
010 |
Eligible Except
Long-Term Care |
013 |
Presumptive Eligibility
Prenatal A |
014 |
Presumptive Eligibility
Prenatal B |
015 |
Perinatal Family |
016 |
MA
Eligible-HR-Utilization Threshold |
017 |
Family Health Plus
Services Only |
018 |
Family Planning
Services Only |
021 |
Record Canceled –
Cancels a Previously Accepted Claim |
All of the following codes are MEVS Denial Codes. Their presence in your response area means the entire transaction has been rejected. If a MEVS Denial Code has a comparable NCPDP Reject Code, both codes will be returned. If there is no comparable code, then NCPDP code 85, "Claim Not Processed" is returned along with the MEVS Code. In those cases, the MEVS Denial Code will further qualify the reason for the claim being rejected. The following chart indicates the relationship between the MEVS Denial Code and any comparable NCPDP Reject Code, if one applies.
Code 999 will be returned if any invalid data is entered in the NCPDP required header fields. For example, an entry of 05 in the Transaction Code field will result in an MEVS Denial Code 999 being returned since it exceeds the number of claims authorized to be sent in a transaction. Also included is a description and relevant comments about the code.
MEVS CODE |
DESCRIPTION |
NCPDP CODE |
DESCRIPTION |
001 |
Not MA Eligible |
65 |
Patient is Not Covered |
030 |
Expired Card |
07 |
M/I Cardholder ID
Number |
031 |
Invalid Card Status |
07 |
M/I Cardholder ID
Number |
033 |
Non-Current Card |
07 |
M/I Cardholder ID
Number |
045 |
No Authorization Found |
87 |
Reversal Not Processed |
050 * |
Alternate Access Not
Allowed |
** |
|
051 |
Invalid Provider Number |
05 |
M/I Pharmacy Number |
052 |
Provider Not on File |
50 |
Non-Matched Pharmacy
Number |
053 |
SSN Access Not Allowed |
07 |
M/I Cardholder ID
Number |
054 |
Provider Cannot Access
by Account Type |
** |
|
055 |
Provider Not Eligible |
** |
|
056 * |
Re-enter Ordering
Provider Number |
25 |
M/I Prescriber ID |
059 * |
Invalid License Type |
25 |
M/I Prescriber ID |
061 * |
Invalid Access Number |
07 |
M/I Cardholder ID
Number |
062 * |
Invalid Medicaid Number |
07 |
M/I Cardholder ID
Number |
063 * |
Invalid Sequence Number |
08 |
M/I Person Code |
065 |
Recipient Not on File |
52 |
Non Matched Cardholder
ID |
066 |
Disqualified Ordering
Provider |
25 |
M/I Prescriber ID |
067 |
Deceased Ordering
Provider |
25 |
M/I Prescriber ID |
068 |
Invalid Ordering
Provider |
25 |
M/I Prescriber ID |
071 |
Invalid Date |
15 |
M/I Date Filled |
092 |
Invalid Specialty Code |
05 |
M/I Pharmacy Number |
100 * |
Invalid Referring
Provider Number |
35 |
M/I Primary Prescriber |
101 * |
Restricted Recipient No
Auth |
35 |
M/I Primary Prescriber |
103 |
No Coverage: Pending
Family Health Plus |
65 |
Patient Not Covered |
104 |
No Coverage: Excess
Income |
65 |
Patient Not Covered |
105 |
QMB Requires Medicare
Approval |
65 |
Patient Not Covered |
118 * |
MCCP Recipient No Auth |
35 |
M/I Primary Prescriber |
300 |
Service Date Prior to
Birthdate |
09 |
M/I Birthdate |
302 |
Provider Ineligible
Service on Date Performed |
** |
|
303 |
Prior Approval
Indicated Denied/Rejected by NYS |
30 |
M/I PA/MC CODE |
304 |
Recipient ID Unequal to
Prior Approval File |
30 |
M/I PA/MC CODE |
305 |
Child Care Recipient –
Bill Agency |
** |
|
307 |
Prior Approval Units or
Payment Amount Exceeded |
** |
|
308 |
Service Date Not Within
Prior Approval Range |
** |
|
309 |
Claim Type Unequal to
Prior Approval Record Class |
** |
|
310 |
Pharmacy Service
Included in In-state Facility Rate |
** |
|
312 |
Pregnancy Indicated –
Invalid for Recipient Sex or Age |
** |
|
313 |
Provider Reimbursed for
Medicare Only |
** |
|
314 |
Recipient Not QMB,
Services Not Reimbursable |
** |
|
315 |
Recipient Not Medicare,
Services Not Reimbursable |
** |
|
316 |
Claim Previously Paid
Using Another Provider Number |
** |
|
318 |
Prescribing Provider
License Not in Active Status |
25 |
M/I Prescriber ID |
320 |
Other Insurance
Information Inconsistent |
DV |
|
321 |
Pharmacy Service
Included In Out-of-State Facility Rate |
** |
|
322 |
Online
Adjustments/Rebills Not Allowed For DVS Items/Drugs |
** |
|
323 |
Processor Control
Number Needed for Rebill/Reversal of Paid Claim |
** |
|
324 |
The system or file
necessary to process the transaction is currently unavailable. |
92 |
System Unavailable |
700 * |
Year of Birth Not Equal
to File |
09 |
M/I Birthdate |
701 |
Sex Not Equal to File |
10 |
M/I Sex Code |
702* |
ECCA Not Allowed |
81 04 |
Claim
too Old M/I Processor Control
Number |
703 * |
Invalid PIN |
04 |
M/I Processor Control
Number |
704 * |
Invalid TSN |
04 |
M/I Processor Control
Number |
999 |
Header Field Error |
*** |
|
* For
further explanation and examples of error conditions refer to Table 2 Error
Chart
** NCPDP
equivalent reject code does not exist.
Code 85 "Claim Not
Processed" will be returned.
*** Several
Different NCPDP Reject Codes could be returned with MEVS Code 999. These Reject Codes will indicate which
header field is in error.
TABLE 2 ERROR CHART
Key: b = Blanks/Spaces
Left Justify = Begin in First Position on Left
MEVS CODE |
NCPDP CODE |
EXAMPLES OF CORRECT ENTRY |
COMMON ERRORS BEING MADE / COMMENTS |
050 Alternate
Access not allowed |
None |
None - No entry made |
1.
In order to access the
DUR/ECCA online system you must choose an alternate access method. 2. Code 050 will be returned if your provider number
has not been updated with your selected access method on the eMedNY
contractor’s production file. 3.
In order to be updated
on the production file, you must have: A) Notified the eMedNY contractor of your alternate
access method. B) Signed the contract and sent it to the eMedNY
contractor. C)
Signed the contract
and submitted your check to your switch company if you chose to transmit
through a switch. The switch must
then send an approval to the eMedNY contractor before your number will be
updated on production. |
053 SSN Access Not Allowed |
None |
None – 9 digit entry
not allowed |
Card holder ID field
(302) has only two acceptable formats: 1. Eight
position alpha/numeric Medicaid Client Number (CIN) OR 2. Thirteen-digit Access
Number without the six-digit ISO # prefix |
054 Provider Cannot Access by Account Type |
None |
None – No entry made |
If you submit a
transaction via an access method other than the method assigned to your
provider number on the production file, code 054 will be returned. For
example, if your provider number is on the file as going through a switch
company and a transaction is sent using a second switch company that is not
on your file, your transaction will be rejected. |
Reenter Ordering Provider Number or Invalid License Type |
25 M/I
Prescriber ID |
0100567892 (NYS
Physician) 290F654938 (Nurse
Practitioner) 00240588 (8
digit MMIS Provider ID for enrolled prescriber) 11NJ456193 (Out of State Physician from New Jersey). 250U452749 (Optometrist) |
1. The Prescriber ID field length is 10. The Prescriber's License type must be in the first two
positions, followed by either two zeroes or two alpha (out of state) followed
by the 6 digit license number. An 8
digit provider number must be left justified, space filled. Note: When entering a license number, the last
six positions of the entry should be the actual numeric license number. If the license number does not contain six
numbers, zero fill the appropriate positions preceding the actual license number. For example, an entry for an Optometrist
whose license number is U867 would be 250U000867. 2. Some incorrect entries being received are: A)
567892:
License number only B)
00567892:
License number without License Type. C)
0156892:
License Type, License Number without zeroes or 2 alpha in between. D)
E)
DEA
Number: Some software packages are
sending the physician's DEA numbers instead of the license number. 3.
Nurse Practitioners: A nurse practitioner may have several
different license numbers because the State Education Department issues them
a license for each specialty for which they are certified. Not All Nurse Practitioners are licensed
to prescribe drugs. A nurse
practitioner who is licensed to prescribe will have the letter "F"
preceding the 6 digit license number. This is the license number that must be
used when submitting your transaction.
The license type 29 followed by 0F and the 6 digit number is the only
correct entry for nurse practitioners’ license numbers. 4. Optometrists: An optometrist who is licensed to prescribe will have the
letter ‘U’ or ‘V’ preceding the six -digit license number. The license type
25 followed by ‘OU’ or ‘OV’ and the six- digit number are the only correct
entries for optometrists’ license numbers. |
061 Invalid
Access Number 062 Invalid
Medicaid Number. |
07 M/I
Cardholder ID Number |
2631578424139 (13
digit access number found on recipient's Medicaid card) LZ00083W (CIN Number) |
1.
The entry in the
Cardholder ID field must contain either the recipient's 13 digit access
number or their 8 character alpha numeric CIN number. Both must be left
justified, space filled. 2. The most common error being received that causes
code 061 to be returned is an entry of 8 numeric digits in the Cardholder ID
field. Check your software to make
sure the alpha characters in the CIN number are not being converted to
numeric values. 3. Rejections also occur when either number is not left
justified. 4. Code 062 is returned when the number entered cannot
be found on the file. |
063 Invalid
Sequence Number |
08 M/I
Person Code |
03 (2
digit sequence number) 12 (2
digit sequence number) |
1.
The recipient's 2
digit sequence number is required on each transaction. The sequence number
can be found on the recipient's Medicaid card. 2. Our format requires the 2 digit sequence number to
be placed in the 3 digit Person Code field.
The number must be left justified and space filled. We have learned that some software
packages have the number placed in a different field, which is fine as long
as it is sent to the eMedNY contractor in the Person Code field. 3. Some incorrect entries being received are: A) Person Code field is blank B) Sequence number is not left justified. C)
Sequence number
transmitted does not match the most current number on the eMedNY contractor’s
file. A new sequence number is issued each time a recipient receives a new
card. |
Invalid
Referring Provider Number 101 Restricted
Recipient No Auth 118 MCCP
Recipient No Auth |
35 M/I
Primary Prescriber |
00240588 (8
digit MMIS identification number of the provider to which a recipient is
restricted). |
1.
If a recipient is
restricted, the Primary Prescriber field must contain the 8 digit MMIS
Number that the recipient is restricted to.
The provider number is the only valid entry. An entry in this field is in addition
to an entry in the Prescriber ID field. The entry must be left
justified and space filled. 2. Some incorrect entries being received are: A) B) 00240588bA: Eight digit MMIS Provider number left
justified but followed by a space and an alpha character. C) Field is blank and recipient is restricted. D)
Field contains the
same provider number that is being sent in the Prescriber ID field and
recipient is not restricted to that provider. E)
Field contains a
license number. |
700 Year
of Birth not equal to file. |
09 M/I
Birthdate |
19490228 (Century,
Year, Month, Day) |
The Date of Birth field
requires an 8 digit entry which includes the Century of the recipient's
birth. The majority of your software
packages only require you to enter the birth year and the software is
automatically sending 19 as the Century. This has caused some rejections when
the recipient was born in the 18th Century.
When this occurs, you need to contact your software company. |
702 ECCA
Not Allowed |
81 Claim Too Old |
20010601 (Century,
Year, Month, Day) |
1. The date
filled requires an eight-digit entry which includes the century of the date
filled. The eMedNY contractor will
only accept fill dates up to two years old via NCPDP for rebills and
reversals. This reject will be returned for any rebill or reversal with a
fill date over two years old. |
|
04 M/I Processor Control Number |
Y (Yes) |
2. The first
position of the Processor Control Number must equal ‘Y’ to indicate the
provider has read and attests to the data in the Certification Statement on page 19.0.3. |
703 Invalid
PIN 704 Invalid
TSN |
04 M/I
Processor Control Number |
YTG1234QBK (Certification,
Initials, PIN, TSN) Y (Certification,
Two Blanks, PIN, TSN). If the initials are not sent in the Processor Control
Number field, they must be sent in the Pharmacists Identification field. |
1. If you
wish your transaction to be electronically captured, the Processor Control
Number field must be completed. Correct
completion of this field alerts the on-line system to capture an accepted
claim transaction for adjudication. 2. The
reject denial code 703 will be returned if: A.) You have not
submitted the PIN selection form to the Department of Health. B.) The PIN number has
not been added to your provider file record at the eMedNY contractor. C.) The PIN number
transmitted does not match the number selected, which was added to your
provider file record. 3. The
reject denial code 704 will be returned if: A.) You have not applied for and/or submitted your TSN number on a notarized certification statement to the eMedNY contractor. B.) The
TSN transmitted does not match the TSN submitted on the certification
statement, which was added to the TSN file. 4. Some software
has hard coded the TSN of the billing service into this field. If that TSN was not on the certification
statement, the transaction will reject. |
Code |
Description |
127 |
Co-payment
Requirements Have Been Met |
128 |
No Co-payment Required
– Recipient Under 21 or Exempt |
All of the Table 7 codes are denial codes. Their presence in your response means that the claim has been rejected. If none of the Table 7 codes apply to your claim, you will see 000 in your response instead.
MEVS CODE |
DESCRIPTION |
NCPDP CODE |
DESCRIPTION |
132 |
M/I Item / NDC Code |
21 |
M/I NDC Number |
133 |
Item Not Covered for
Patient Gender |
61 |
Drug Not Covered for
Patient Gender |
134 |
Patient Age Exceeds Maximum
Age |
66 |
Patient Age Exceeds
Maximum Age |
135 |
Patient Age Precedes
Minimum Age |
85 |
Claim Not Processed |
136 |
Requested Item Exceeds
Frequency Limitation |
85 |
Claim Not Processed |
137 |
Missing/Invalid
Quantity Dispensed |
18 |
M/I Metric Quantity |
140 |
Category of service not
valid for item / NDC code |
05 |
M/I Pharmacy Number |
142 |
Missing / Invalid
category of service |
05 |
M/I Pharmacy Number |
705 |
NDC/APC Not Covered |
70, 77 |
NDC Not Covered,
Discontinued NDC Number |
706 |
Refill Code Exceeds
Number of Refills Authorized |
17 |
M/I New Refill Code |
707 |
Previously Filled
Refill |
17 |
M/I New Refill Code |
708 |
Exceeds NY Allowed
Refill Maximum |
29 |
M/I Refills Authorized |
709 |
Maximum Day’s Supply
Exceeded |
19 |
M/I Day’s Supply |
710 |
Maximum Quantity
Exceeded |
76 |
Plan Limitations
Exceeded |
711 |
Date Filled Prior to
Date Rx Written |
28 |
M/I Date Prescription
Written |
712 |
Override Denied - UT
not at limit |
34 |
M/I Prescription Denial
Override |
713 |
Refill over 180 days
from Date Rx Written |
28 |
M/I Date Prescription
Written |
714 |
Date Filled More than
60 days from Date Rx Written |
28 |
M/I Date Prescription
Written |
715 |
Other Insurance Amount
must be greater than zero |
13 |
M/I Other Coverage Code |
716 |
Other Insurance Amount
must be equal to zero |
13 |
M/I Other Coverage Code |
717 |
Recipient has Other
Insurance |
13 |
M/I Other Coverage Code |
718 |
HR Recipient - No
Rebate Agreement |
77 |
Discontinued NDC Number |
719 |
MA Only Covers Family
Planning |
65 |
Patient Is Not Covered |
720 |
Days Supply is Less
than the Minimum Required |
19 |
M/I Days Supply |
722 |
Family Health Plus
Denial |
65 |
Patient Not Covered |
The chart starting on the following page lists the most frequently returned reject denial codes from Table 7 and describes the entry errors being received.
MEVS CODE |
NCPDP
CODE |
EXAMPLES
OF CORRECT
ENTRY |
COMMON
ERRORS BEING MADE |
705 NDC/APC
Not Covered |
70 NDC
Not Covered 77 Discontinued
NDC Number |
00074738601 (11
digit NDC Code) |
1.
The NDC field entry
must contain an 11 digit numeric NDC code.
Alpha characters in this field will cause a rejection. 2.
Some common errors
being received are: A) NDC field is blank - software is not pulling code
off of your drug file. B) NDC field is incomplete. Entry does not contain a full 11 numbers, but is a combination
of blanks and numbers. C) A five digit alpha/numeric sickroom supply code is
being transmitted in the NDC field. D) We have learned that some software packages are
converting your 11 digit NDC code entry to a five digit alpha/numeric code
for some over the counter items that used to be billed using the alpha/numeric
code but have now been assigned an 11 digit NDC code. E) Conversely, other software packages are converting
your 5 digit alpha/numeric code entry from the Alternate Product Supply code
field to an 11 digit NDC code. These
items used to be billed using an NDC code but have been changed to a five
digit alpha/numeric code. PLEASE NOTE: If you receive a rejection code for your
NDC entry, you should check with your software vendor to see what code is
being transmitted. F)
The Compound Code
field must contain a value of 1 for each NDC entry. An entry of any other code in the compound code field when
submitting an 11 digit NDC code will cause a rejected claim. |
710 Maximum
Quantity Exceeded |
76 Plan
Limitations Exceeded |
00100 (100
Tablets) 00001 (1
package of gauze pads) 00075 (75
Caloric Units) |
1.
The Metric Quantity
field is a five digit numeric field.
The first digit must always be a zero as New York State cannot accept
a quantity greater than 09999. 2. The quantity that you enter in this field is checked
against the maximum quantity on the Drug Plan File for each drug or supply
item. If the amount entered exceeds
the amount on the Drug Plan File, the claim will deny. 3. If you have received prior approval to dispense a
quantity that exceeds the established maximum, you must enter the prior
approval number on your transaction.
This will allow your claim to override the edit. 4. Some incorrect entries being received are: A) 12652 - A five digit number cannot be entered. B) 12650 - Number is left justified instead of right
justified. The zero must be in the
first position. C)
00500 - The number of
items in a box or package are being submitted rather than the number of boxes
or packages. If there are 500 gauze
pads in 1 box, the quantity should be submitted as 00001. |
712 Override
Denied UT Not at Limit |
34 M/I
Prescription Denial Override |
00 (No
Override required) 01 (No
Override Required) 02 (UT
Service Authorization Exception Code P - Override Pending) 07 (UT
Service Authorization Exception Code J or L - Immediate Urgent Care or
Emergency) |
1.
An entry must be
placed in the Prescription Denial Clarification field. 2. If the recipient is not at their UT limit, 00 or 01
should be entered. 3. If the recipient is at their limit, value 02 or 07
should be entered to override the limit. 4. Code 712 is returned if a value of 02 or 07 is
entered and the recipient has not reached their limit. |
CODE |
DESCRIPTION |
APPROVAL OR DENIAL |
PROCESSING RESULTS DESCRIPTION |
AA |
UT Approved, P&C
Approved |
A |
UT&P&C S/A |
AD |
UT Approved, Services
Not Ordered |
D |
No S/A |
AN |
UT Approved, P&C
Not Invoked |
A |
UT S/A |
DA |
UT At Service Limits,
P&C Approved |
D |
No S/A |
DD |
UT At Service Limits,
Services Not Ordered |
D |
No S/A |
DN |
UT At Service Limits,
P&C Not Invoked |
D |
No S/A |
LA |
UT Approved Near
Limits, P&C Approved |
A |
UT&P&C S/A |
LD |
UT Approved Near
Limits, Services Not Ordered |
D |
No S/A |
LN |
UT Approved Near
Limits, P&C Not Invoked |
A |
UT S/A |
NA |
UT Not Invoked, P&C
Approved |
A |
P&C S/A |
ND |
UT Not Invoked,
Services Not Ordered |
D |
No S/A |
NN |
UT Not Invoked, P&C
Not Invoked |
A |
Exempt - No S/A
Necessary |
PA |
UT Override Denied,
P&C Approved |
D |
No S/A |
PD |
UT Override Denied,
Services Not Ordered |
D |
No S/A |
PN |
UT Override Denied,
P&C Not Invoked |
D |
No S/A |
XX |
DUR Denial |
D |
No S/A |
Table 8 codes were formulated to return a code which combines the Utilization Threshold (UT) and Post and Clear (P&C) programs. The first alpha character indicates the UT status; the second character indicates the P&C status. Both characters must indicate an approval in order for service authorizations to be generated. The key to recognizing an approval code:
The first character must be an "A", "L", or "N” and
The second character must be an "A" or "N".
The only Table 8 codes that indicate an approval for a UT and/or P&C service authorization are:
AA (UT and P&C service authorization)
AN (UT only, P&C exempt)
LA (UT and P&C service authorization)
LN (UT only - P&C exempt)
NA (UT exempt, P&C service authorization)
NN (UT exempt, P&C exempt)
PLEASE NOTE: Although these are approval codes, the approval is for the UT and P&C programs only. The claim must pass all other editing in order for the authorizations to be considered approved for payment. If the response status field contains a "C" (Claim Captured), any necessary service authorizations have been established. If the response status field contains an "R" (Rejected), no authorizations are generated. A Table 8 code is returned in every response even if the claim is rejected.
The third column in Table 8 lists the approval (A) or denial (D) status of each code.
The fourth column in Table 8 indicates whether service authorization requirements were satisfied.
Not invoked means that the claim did not have to be processed through that designated program. For example: UT Not Invoked means that the claim was not processed through the UT program for various reasons. (Recipient may be exempt from UT, etc).
If the claim is denied for DUR (Code XX), the UT and P&C status code will not be displayed because the UT, P&C approval has been negated by the DUR denial.
CODE |
DESCRIPTION |
129 |
Duplicate/Redundant DVS
request |
130 |
DVS process was not invoked |
131 |
Item approved / DVS number
issued |
132 |
Missing / Invalid item /
NDC code |
133 |
Item not covered for
patient gender |
134 |
Patient age exceeds maximum
age |
135 |
Patient age precedes
minimum age |
136 |
Requested item exceeds
frequency limitation |
137 |
Missing / Invalid quantity
dispensed |
139 |
DVS requires current date
entry |
140 |
Category of service not
valid for item / NDC code |
142 |
Missing / Invalid category of service |
705 |
NDC/APC Not Covered |
710 |
Maximum Order Quantity
Exceeded |
CODE |
DESCRIPTION |
301 |
Pending for Manual
Pricing. (The NDC being billed
requires manual review and pricing by DOH). |
306 |
Item Requires Manual
Review. (The NDC being billed
requires manual review by DOH prior to payment). |
311 |
PCP Plan Code Not on
Contract File. (Recipient is enrolled
in a managed care plan but the plan code has not yet been added to DOH’s
Managed Care Contract file). Call
Provider Services 1-800-343-9000 |
317 |
Claim Pending: Excess Income/Spenddown. (Recipient has income in excess of the
allowable Medicaid levels and will be considered eligible for Medicaid
reimbursable services only at the point his/her excess income is reduced to
the appropriate level. This response
will be issued if you override the excess income denial [code 104] and the
LDSS has not yet updated eligibility on the Client database). |
319 |
Prior Approval Not on
or Removed From File. (PA is not
found on or no longer active on the eMedNY contractor’s PA file). |
Note: These codes may appear in the Table 2 response area for non-ECCA transactions since non-ECCA transactions will not be held in a pending status. They will be rejected if the conditions for these reason codes exist.
CODE |
DESCRIPTION - M/I = Missing/Invalid |
MEVS CODE |
01 |
M/I BIN |
|
04 |
M/I Processor Control
Number |
702,703, 704 |
05 |
M/I Pharmacy Number |
051, 092, 140, 142 |
07 |
M/I Cardholder ID
Number |
030, 031, 033, 061, 062 |
08 |
M/I Person Code |
063 |
09 |
M/I Birthdate |
300, 700 |
10 |
M/I Sex Code |
701 |
13 |
M/I Other Coverage Code |
715, 716, 717 |
14 |
M/I Eligibility
Override Code |
|
15 |
M/I Date Filled |
071 |
16 |
M/I Prescription Number |
|
17 |
M/I New-Refill Code |
706, 707 |
18 |
M/I Metric Quantity |
137 |
19 |
M/I Days Supply |
709, 720 |
20 |
M/I Compound Code |
|
21 |
M/I NDC Number |
132 |
22 |
M/I Dispense as Written
Code |
|
25 |
M/I Prescriber ID |
056, 059, 066, 067, 068, 318 |
28 |
M/I Date Prescription
Written |
711, 713, 714 |
29 |
M/I Refills Authorized |
708 |
30 |
M/I P.A./M.C. Code |
303, 304, 319 |
34 |
M/I Prescription Denial
Override |
712 |
35 |
M/I Primary Prescriber |
100, 101, 118 |
50 |
Non-Matched Pharmacy
Number |
052 |
52 |
Non-Matched Cardholder
ID |
065 |
61 |
Drug Not Covered For
Patient Gender |
133 |
65 |
Patient is Not Covered |
001, 103, 104, 719, 722 |
66 |
Patient Age Exceeds
Maximum Age |
134 |
70 |
NDC Not Covered |
705 |
75 |
Prior Authorization
Required |
|
76 |
Plan Limitations
Exceeded |
710 |
77 |
Discontinued NDC Number |
705, 718 |
81 |
Claim Too Old |
702 |
82 |
Claim is Post Dated |
|
83 |
Duplicate Paid/Captured
Claim |
|
84 |
Claim Has Not Been
Paid/Captured |
|
85 |
Claim Not Processed |
|
87 |
Reversal Not Processed |
045 |
88 |
DUR Reject Error |
|
92 |
System Unavailable |
324 |
DQ |
M/I Usual and Customary |
|
DV |
M/I Other Payor Amount |
320 |
DX |
M/I Patient Paid Amount |
|
E1 |
Alternate Product Type |
|
E2 |
Alternate Product Code |
|
E4 |
DUR Conflict Code |
|
E6 |
DUR Outcome Code |
|
E9 |
Pharmacist's ID |
|
MZ |
Error Overflow |
|
Up to twenty (20) NCPDP reject codes can appear in the rejected response. If a code has a comparable MEVS reject code that code will also be returned in the response. Most of the NCPDP reject codes are self-explanatory or have been further explained in other sections. Those needing further clarification are described below.
Code 22 - M/I Dispense As Written Code:
An entry is required. The acceptable values are:
0 - No Product Selection Indicated.
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 marketplace.
Code 30 - M/I P.A./M.C. Code:
If an NDC or APC requires a prior approval number, the prior approval field must contain the prior approval number assigned to you for the NDC or APC. The prior approval field is 12 digits in length. The entire field must be completed. The first digit should always be a 1 followed by the 8 digit prior approval number with three zeroes or co-pay exemptions following. Example 156734268000. Additionally, if you are submitting claims using the NCPDP RTDS “3A” fixed format, the field needs to be zero filled if a prior authorization is not required for the NDC code. Refer to Section 2.11 for field values.
Code 83 - Duplicate Paid/Captured Claim:
This code is returned when a claim is submitted and the Pharmacy Number, Cardholder ID, Date Filled, and Prior Approval Number fields match a previously paid claim and one of the following three conditions also exist:
· Prescription Number, NDC/APC (if not a compound), and Generic Code match, but the New/Refill Code is different.
· Prescription Number and Generic Code match, but NDC/APC is different
· NDC/APC (if not a compound) match, but Prescription Number is different.
Refer to section 2.14 for additional information.
Code 84 - Claim Has Not Been Paid/Captured:
This code is returned when a transaction is submitted (transactions codes 81-84) with the intent of supplying DUR information only for purposes of updating the recipient's drug history file when no claim submission or reimbursement is allowed or expected. If Code 84 is the only code returned, the drug history file has been updated.
DQ - M/I Usual and Customary:
An entry is required in the Usual and Customary Charge field. If the claim is being sent for ECCA processing, the amount in this field must be greater than zeroes. If ECCA is not being requested, the field must be zero filled.
Several abbreviations are used when referring to the Drug Utilization Program. These abbreviations are listed below with a brief description.
APC |
Alternate Product Code a/k/a/ Product Supply Code. The five digit alpha/numeric code assigned by New York State to over the counter sickroom supplies. These codes are found on pages 4-9 through 4-31 of the MMIS Pharmacy Provider Manual. The five digit alpha/numeric DME item codes are also entered as APC codes for DVS Transactions. |
CPU |
Central Processing Unit. This is also known as the mainframe computer. |
CPU-CPU Link |
A direct telecommunication connection to the eMedNY contractor’s mainframe computer using a central processing unit to access the MEVS/Pro-DUR systems. |
DME |
Durable Medical Equipment. These items and their codes are listed in the DME MMIS Provider Manual and are further identified by use of specialty code 307 or category of service 0442 when billing and must be submitted on a DME claim form. Some DME item codes require a DVS number. |
DVS |
Dispensing Validation System. This feature allows you to obtain the required prior approval number (DVS number) for pre-designated DME item codes and certain prescription drugs in the same transaction as your DUR/ECCA claim. Items, which are only reimbursable under COS 0442, can also be submitted through the NCPDP format but not for DUR/ECCA. |
ECCA |
Electronic Claims Capture and Adjudication. This is an optional feature of the Pro-DUR program, which allows you to have your DUR claim captured and adjudicated for payment by the eMedNY contractor. |
MEVS |
Medicaid Eligibility Verification System. The system which processes providers’ eligibility inquiries and service authorization requests for New York State Medicaid recipients. |
LICENSE TYPE |
Two digit code indicating the type of provider that wrote the prescription. The valid license types are: 01 NYS Physician 02 NYS Dentist 09 NYS Physician Assistant 25 NYS Optometrist 26 NYS Podiatrist 27 NYS Audiologist 29 NYS Nurse Practitioner/Midwife 11 Out-of-State Physician 12 Out-of-State Dentist 19 Out-of-State Physician Assistant 35 Out of State Optometrist 36 Out-of-State Podiatrist 37 Out-of-State Audiologist 39 Out-of-State Nurse Practitioner/Midwife |
MAGNETIC MEDIA |
Tape, Cartridge, or Diskette used to submit claims for processing. |
NCPDP |
National Council for Prescription Drug Program. A nonprofit membership organization working toward the standardization and efficiency of third party prescription drug program processing. New York State is using NCPDP's Version 3.2 variable and fixed RTDS-A formats to administer the DUR program. |
NDC |
National Drug Code. The eleven digit number assigned to each drug or OTC item. |
NYSDOH |
New York State Department of Health |
OTC |
Over the Counter drug or supply which does not require a prescription. |
P & C |
Post and Clear. The program in effect which requires certain prescribers to post their prescriptions on the MEVS system. The posted prescriptions must then be "cleared" by the dispensing provider. P & C service authorizations are required for payment to be made. |
PC |
Personal Computer. |
PC-Host Link |
A dial up into the MEVS network using a personal computer to access the MEVS/Pro-DUR systems. |
PIN |
Personal Identification Number. A four digit number selected by each pharmacy and submitted to the New York State Department of Health for input to the pharmacy's provider file. Pharmacies must enter the number on each Pro-DUR transaction in order to have their claim electronically captured and submitted for adjudication. |
Pro-DUR |
Prospective Drug Utilization Review. This is a mandatory program, which alerts pharmacists to possible contraindications when dispensing drugs to a recipient. |
RTDS-3A |
Recommended Transaction Data Set established by NCPDP for electronic transmission of pharmacy claims in a fixed format. |
Switch (Switching) |
A company that passes the Pro-DUR/ECCA transaction from the provider to the MEVS network, via a dedicated telecommunications link, and returns the response from the MEVS network to the provider. |
TSN |
Transmission Supplier Number. A three-character code assigned by the eMedNY contractor to a provider who wishes to send their claims electronically or via magnetic media. The Transmission Supplier Number has also been referred to as a Magnetic Supplier Number. Each pharmacy must submit their TSN with a notarized certification statement to the eMedNY contractor. The TSN must be entered on each Pro-DUR transaction in order to have the claim electronically captured. |
UT |
Utilization Threshold. The mandatory program in effect, which limits Medicaid recipients to a designated number of services, prescriptions, etc. per year. Providers must receive a UT service authorization in order for payment to be made. |
A: If you have any questions regarding your software, refer them to your software vendor. The New York State Department of Health and the eMedNY contractor do not have any control over software written to interface with the Pro-DUR/ECCA system.
Q: What phone number do I dial to access the production Pro-DUR/ECCA system?
A: For PC-Host going direct to the eMedNY contractor, you will receive the production phone numbers once you have completed certification and testing.
For providers going through a switch, you should contact your switch for access procedures and information.
Q: What is my PIN?
A: The Provider Services Department staff can verify if the PIN you are using is correct. They are not authorized to give out your PIN number for security reasons. If you do not know your PIN number, you must complete a new "PIN Selection Form" and return it to New York State Department of Health.
Q: What is my TSN?
A: Contact Provider Services at 1-800-343-9000 for the TSN that is authorized for electronic processing.
Q: Will my claim be paid?
A: If your claim is electronically captured and approved for payment, your claim will be paid. One exception to this rule is for excess income/spenddown. Once you have overridden the 104 denial response, your claim will pend waiting for an eligibility update from the WMS. If the update is not timely, your claim will release from its pending status and deny. These “captured, then denied” claims will appear on your remittance statement as being denied. Refer to the Electronic Claims Capture and Adjudication section of the manual for additional information.
Q: Why am I getting "NO CLAIM TO FA"?
A: You receive this message any time the system has determined the claim can not be captured for adjudication. There are many reasons for this, including if the Processor Control Number is not submitted. Refer to the Electronic Claims Capture and Adjudication section of the manual for additional information.
Q: Will this claim be paid on-line?
A: Your claim will be fully adjudicated. Claims approved for payment will appear as paid within the remittance statement issued for that payment cycle.
Q: What is Person Code?
A: The Person Code is the NCPDP field used to input the Recipient's Sequence Number. The sequence number can be found on the recipient's card.
Q: I received a DUR warning for high dosage and refills too early and my claim was denied? Why?
A: In the on-line Pro-DUR/ECCA system, the eMedNY contractor sends back warning information about certain drug interactions. These are only warnings and are NOT rejects in the on-line system. Some software companies will treat these warnings as REJECTS when interpreting the DUR response. You need to talk to your software provider to determine how to deal with this condition.
Q: What is the valid NDC code for a particular drug?
A: You should look at the microfiche you receive from New York Medicaid. All reimbursable drugs are listed. If you cannot find it, you can call New York State Department of Health at 1-518-486-3209.
Q: What is the proper procedure for entering sickroom supplies (alternate product codes) or Z-coded items?
A: Refer to Section 2.8 on Alternate Product Codes in the manual for clarification.
Q: Was a UT service authorization produced by the eMedNY contractor?
A: Refer to Table 8 UT, P&C codes in this manual for clarification.
Q: Why am I getting M/I PA/MC Code? This doesn't need a PA!
A: If the item you are entering does not need Prior Approval/Authorization and you're using the variable format, only enter spaces in the field. For the variable format, 32, the field should not be transmitted (your software system should take care of this). For the fixed format, 3A, or variable format if the field is being sent, the field should contain zeroes.
Q: How should the PA/MC Code be put in the field?
A: This is a 12 position field where:
Position 1 = one (1).
Positions 2 thru 9 = prior approval number.
Positions 10 thru 12 = zeroes (000) or co-pay exempt values.
Refer to Section 2.11 for field description.
Q: Why was I rejected?
A: Refer to Tables 2, 7, 8, 9 and the NCPDP Reject Codes list for clarification.
Q: What were my DUR reject codes, I cleared my screen already?
A: You should first check with your software vendor to see if there is a method of recovering or re-displaying the response for a transaction. If there is not, you can resubmit the transaction and get the same errors.
Q: I received DUR Reject Code 85 in my response, what does it mean?
A: You should look for the accompanying error codes that are part of the response in the Message field. The first is the MEVS Accepted or Denial code. This code is in the first three positions. The other code is the Rx Denial Code. It follows the MEVS code and a space. Additionally, the claim could be rejected because of UT/P&C denials or DVS denials. Refer to Tables 2, 7, 8, and 9 in this manual.
Q: Why does it say M/I NDC or NDC Not Covered, when the NDC is in fact covered?
A: Refer to Table 7 error chart for further explanation.
Q: What is Maximum Quantity, or Plan Limitations exceeded?
A: The maximum quantity or plan limitations reject is when the amount in the Metric Quantity field is greater than the allowed or approved New York State Medicaid quantity. For assistance call Provider Services at 1-800-343-9000.
Q: I am getting a reject code of 100 or 101, what do I do?
A: Refer to Table 2 error chart for further explanation.
Q: What is E4 DUR Conflict Code or E6?
A: These are both NCPDP Reject Codes. The E4 code indicates there is a problem with the DUR Conflict Code input with the claim. It could be because the data is not one of the DUR reject conflict codes, a DUR override was not required, or the field was the wrong size. The E6 code indicates there is a problem with the DUR Outcome Code. The common problems are a DUR override is not needed or the wrong value was input. Another common problem is only one of the fields is entered. Both fields should be reviewed and the transaction resubmitted. Refer to the Override Processing section for further clarification.
Q: How do I process an override?
A: There are three types of overrides for transactions. The first is the MEVS UT or Utilization Threshold override. It is entered in NCPDP field 420, Prescription Denial Clarification. The UT override is needed when you receive a UT Denial or a D in the first position of the codes for UT/PC in field 504, Message. The second override is for DUR. This is entered in field 439, DUR Conflict Code. The DUR override is required when you receive a DUR Reject, error code 88. Both can be entered in the same transaction. Beware; if the override is not required, the transaction will be rejected. Refer to the Override Processing section for further clarification. The third override is the excess income/spenddown override. This override can be entered in field 309 to override response code 104. Once overridden, your claim will be captured if the processor control number field is completed properly. Once captured, your claims will pend, waiting for a WMS eligibility update to occur. If the update is not timely, your claim will appear as denied on your remittance statement.
The following forms are included in the manual:
Personal Identification Number Request
Certification Statement
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Return To: New York State Department of Health Suite 608 99 Washington Avenue Albany, NY
12210 Attn:
Diane Sumell |
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TSN (1) BILLING
SERVICE NAME (IF APPLICABLE (2)
MEDICAID MANAGEMENT INFORMATION SYSTEM
As of (date) (3) and for one year after this date all claims
electronically submitted to the State's Medicaid fiscal agent, for services or
supplies furnished by (provider name) (4) (provider
number) (5) will be subject to the following
certification.
I am (or the business entity
named in this form of which I am a partner, officer or director is) a qualified
provider enrolled with and authorized to participate in the New York State
Medicaid Assistance Program and in the profession or specialties, if any,
required in connection with this claim;
the persons providing services, care and supplies have the necessary
licensing, certification, training and experience to perform the claimed
service; I have reviewed these claims;
I (or the entity) have furnished or caused to be furnished the care, services
and supplies itemized and done so in accordance with applicable federal and
state laws and regulations; I have read the Medicaid Management Information
Systems Provider Manual and all revisions thereto; all claims are made in full
compliance with the pertinent provisions of the manual and revisions; all
claims for care, services and supplies provided at the order of another
professional have to the best of my knowledge been ordered by that professional
in bona fide compliance with the procedures set forth in the manual and
revisions. All care, services and supplies
for which claim is made are medically necessary for the treatment of the named
recipients, the amounts listed are due and except as noted, no part thereof has
been paid by, or to the best of my knowledge is payable from any source other
than the Medical Assistance Program, payment of fees made in accordance with
established schedules is accepted as payment in full other than a claim
rejected or denied or one for adjustment, no previous claim for the care,
services and supplies itemized has been submitted or paid; ALL STATEMENTS, DATA
AND INFORMATION TRANSMITTED ARE TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY
KNOWLEDGE; NO MATERIAL FACT HAS BEEN OMITTED; I UNDERSTAND THAT PAYMENT AND
SATISFACTION OF THIS CLAIM WILL BE FROM FEDERAL, STATE AND LOCAL PUBLIC FUNDS
AND THAT I MAY BE PROSECUTED UNDER APPLICABLE FEDERAL AND STATE LAWS FOR ANY
FALSE CLAIMS, STATEMENTS OR DOCUMENTS OR CONCEALMENT OF A MATERIAL FACT: taxes from which the state is exempt are
excluded; all records pertaining to the care, services and supplies provided
including all records which are necessary to disclose fully the extent of care,
services and supplies provided to individuals under the New York State Medical
Assistance Program will be kept for a period of six years from the date of
payment, and such records and information regarding these claims and payments
therefore shall be promptly furnished upon request to the local or State
Departments of Health, the State Medicaid Fraud Control Unit or the Secretary
of the Department of Health and Human Services; there has been compliance with
the Federal Civil Rights Act of 1964 and with section 504 of the Federal
Rehabilitation Act of 1973, as amended, which forbid discrimination on the
basis of race, color, national origin, handicap, age, sex and religion: I agree
(or the entity agrees) to comply with the requirements of 42 CFR Part 455
relating to disclosures by providers; the State of New York through its fiscal
agent or otherwise is hereby authorized to (1) make administrative corrections
to claims submitted under this agreement to enable its automated processing,
subject to reversal by provider, and (2) accept the claim submitted under this
agreement as original evidence of care, services and supplies furnished.
In submitting claims under
this agreement I understand and agree that I (or the entity) shall be subject
to and bound by all rules, regulations, policies, standards, fee codes and
procedures of the New York State Department of Health as set forth in title 18
of the Official Compilation of Codes, Rules and Regulations of New York State
and other publications of the Department, including Medicaid Management
Information System Provider Manuals and other official bulletins of the
Department. I understand and agree that
I (or the entity) shall be subject to and shall accept, subject to due process
of law, any determinations pursuant to said rules, regulations, policies
standards, fee codes and procedures, including, but not limited to, any duly
made determination affecting my (or the entity's) past, present or future
status in the Medicaid program and/or imposing any duly considered sanction or
penalty.
I UNDERSTAND THAT MY SIGNATURE HEREON GUARANTEES THE
ABOVE CERTIFICATION WILL APPLY TO ALL ELECTRONIC CLAIMS SUBMITTED, USING MY (OR
THE ENTITY'S) MEDICAID PROVIDER IDENTIFICATION NUMBER.
(Signature) (6)
(Date) (7)
(Typed Name and Title) (8)
STATE OF NEW
YORK
COUNTY OF NEW YORK (9)
On this
day of ,
19 ,before me personally came , to me known and known to me to
be the individual described in and who executed the foregoing instrument, and
(s)he acknowledged to me that (s)he executed the same.
(SEAL)
NOTARY PUBLIC
Electronic Billing Certification Statement
Instructions
Field (1): TSN (Magnetic Supplier Number)
Please indicate the TSN under which the claims are being transmitted.
Field (2): BILLING SERVICE NAME
If applicable, enter the name of the billing service that the provider is enrolled with. If not using a billing service, leave this field blank.
Field (3): DATE
Enter the date the Certification Statement is signed and notarized (same date as Field 7).
Field (4): PROVIDER NAME
Enter the name of the provider whose signature is being notarized.
Field (5): PROVIDER NUMBER
Enter the 8-digit Medicaid provider ID number which was assigned by the Department of Health at the time of the provider's enrollment. This must be the individual provider number, not a group number or license number.
Field (6): SIGNATURE
Enter the signature of the individual indicated in Field 4. The signature must be original.
Field (7): DATE
Enter the date the Certification Statement is signed and notarized.
Field (8): NAME AND TITLE
Print the name and the title of the individual whose signature appears in Field 6.
Field (9): NOTARY PUBLIC
To be completed and signed by the Notary Public. Certification Statements that are not notarized cannot be accepted by the fiscal agent.
PLEASE NOTE:
Electronic Billing Certification must be renewed annually. Renewal documents will be provided prior to certification expiration.