Claims Processed Before March 1, 2010

Point-of-Sale Claims

BadgerCare Plus, Medicaid, and SeniorCare use a voluntary pharmacy POS electronic claims management system for fee-for-service and SeniorCare members. The POS system enables providers to submit electronic pharmacy claims for legend and OTC drugs in an online, real-time environment.

The pharmacy system verifies member enrollment and monitors pharmacy policy. Within seconds of submitting a real-time claim, these processes are completed and the provider receives an electronic response indicating payment or denial.

National Council for Prescription Drug Programs 5.1 Telecommunications Standard Claims

BadgerCare Plus, Medicaid, and SeniorCare use the NCPDP Telecommunication Standard Format Version 5.1. Using this format, providers are able to complete the following:

• Initiate new claims and reverse and resubmit previously paid real-time claims.
• Submit individual claims or a batch of claims for the same member within one electronic transmission.
• Submit claims for PC.
• Submit claims for compound drugs.

National Provider Identifier On National Council for Prescription Drug Programs 5.1 Telecommunications Standard Claims

An NPI is required on NCPDP 5.1 transactions. There are no data elements for other NPI-related data, taxonomy code, or ZIP+4 code on the NCPDP 5.1 transaction. Providers who do not have a unique NPI for each certification are required to select one certification as the "default" certification. Claims will be processed using the provider file information from the default certification.

An NPI only is accepted in the Prescriber ID field of NCPDP 5.1 transactions. Billing providers may indicate the prescriber's NPI or the pharmacy's NPI.

Prescriber ID and Prescriber ID Qualifier

An NPI is the only identifier accepted in the Prescriber ID field on pharmacy claims, including paper claims. Billing providers are required to make every effort possible to obtain the prescribing provider's NPI. Only in instances when the billing provider is unable to obtain the prescriber's NPI, may the billing provider indicate his or her own NPI in the Prescriber ID field. DEA numbers, including "default" DEA numbers, are not accepted for the Prescriber ID on pharmacy claims.

The Prescriber ID Qualifier value "01" is the only value accepted for the Prescriber ID Qualifier. A value of "01" in the Prescriber ID Qualifier field (466-EZ) indicates that the Prescriber ID field (411-DB) contains an NPI for the prescribing provider. Real-time and PES claims submitted without "01" are denied.

Claim Submission Requirements

When submitting claims for other insurance to ForwardHealth, providers are required to include specific COB information based on the results of the claim submission to other insurance sources. Some or all of the information below may be automatically populated by the pharmacy software; however, if the software does not automatically populate this information, pharmacy providers are required to enter the information before submitting the claim.

If a service is covered by other insurance and payment is collected, providers are required to indicate a value of "2" in NCPDP field 308-C8 (Other Coverage Code) and information in the following NCPDP fields for each other insurance source:

• 338-5C (Other Payer Coverage Type).
• 340-7C (Other Payer ID).
• 339-6C (Other Payer ID Qualifier) with a value of "99."
• 443-E8 (Other Payer Date) with the payment date, denial date, or the date the claim was submitted to other insurance sources.
• 431-DV (Other Payer Amount Paid) with amount paid by other insurance sources.
• 342-HC (Other Payer Amount Paid Qualifier) with a value of "08."

If a service is not covered by other insurance or if payment is not collected, providers are required to indicate the appropriate value in NCPDP field 308-C8 (Other Coverage Code) and information in the following NCPDP fields for each other insurance source:

• 338-5C (Other Payer Coverage Type).
• 340-7C (Other Payer ID).
• 339-6C (Other Payer ID Qualifier) with a value of "99."
• 443-E8 (Other Payer Date) with the payment date, denial date, or the date the claim was submitted to other insurance sources.
• 471-5E (Other Payer Reject Count) with the number of reject codes to follow.
• 511-FB (Reject Code) with the error code provided by the other insurance source.

Lists of common COB errors and resolutions and COB examples are available.