Kentucky Web Claims Submission User Guide...Jun 26, 2014 · Kentucky Web Claims Submission User Guide Confidential and Proprietary Page 4 1.0 Introduction The Web Claims Submission

Proprietary & Confidential © 2014, Magellan Health Services, Inc. All Rights Reserved.

Kentucky Web Claims Submission User Guide Version 1.1 June 26, 2014

Kentucky Web Claims Submission User Guide

Confidential and Proprietary Page 2

Revision History

Document Version Date Name Comments

1.0 06/18/14 Training and Development Department Initial Creation of Document

1.1 06/26/14 Training and Development Department Updated Prescriber segment


Page 3 Magellan Medicaid Administration

Table of Contents Revision History .................................................................................................................................2 Table of Contents ...............................................................................................................................3 1.0 Introduction ..........................................................................................................................4

1.1 Payer Specification Document..................................................................................................... 4 2.0 Submitting a Claim .................................................................................................................6

2.1 Submitting a Multi-Claim Transaction ....................................................................................... 19 3.0 Claim Submission Response ................................................................................................. 22 4.0 Searching for a Claim ........................................................................................................... 24

4.1 Resubmitting a Claim ................................................................................................................. 28 5.0 Glossary............................................................................................................................... 32 6.0 Acronyms ............................................................................................................................ 40 7.0 Index ................................................................................................................................... 44



1.0 Introduction The Web Claims Submission (WCS) tool allows pharmacy staff members to enter and search for claims. To gain access to the Web Claims Submission tool, a designated staff member has to complete registration.

1.1 Payer Specification Document

A Payer Specification document outlines the necessary information (fields) and valid field values for claim submission. Data fields are also displayed on the Claims Entry template in the same segments that they are listed under in the Payer Specification document. This document provides you with a list of required and situational fields and valid values for those fields when submitting a claim using Web Claims Submission. The Payer Specification document can be found on the website.

For Example: The following fields are listed under the Request Header Segment in the Payer Specification document: Bin Number, Version/Release Number, Transaction Code, Processor Control Number, Transaction Count, Service Provider ID Qualifier, Service Provider ID, Date of Service, and Software Vendor/Certification ID. Many of the same fields are located on the Claims Entry template under the Request Header Segment. See Figure 2.0.3.





2.0 Submitting a Claim To submit a claim, please use the following steps:

1. From the Service Provider List window, select the provider ID from the list. See Figure 2.0.1.

Figure 2.0.1 – Web Claim Submission, Service Provider List Window

2. Click Select. The Adjudicated Claims Search window appears. See Figure 2.0.2.

Figure 2.0.2 – Adjudicated Claims Search Window

3. Click the appropriate claim template from the listing. Refer to Figure 2.0.2. The Claim Submission Data Entry window appears. See Figure 2.0.3.



• Fields with the Orange icon are required fields.

• The Claim Entry template times out after 15 minutes of inactivity.

Figure 2.0.3 – Claim Data

Claim Data Section

Field Description

Template Name of claim submission data entry template

Host/Port Website form that is submitted to Magellan Medicaid Administration and the computer connection

Trial Adjudication Click to adjudicate claim without committing the claim to production; once you are ready to submit a claim and for it to be recorded, clear the Trial Adjudication check box

Submits the claim(s) as entered

Access a new claim template

Clears all entered information on the template

Returns to the Claims Submission Main window



• Not all headers and segments for the Web Claims Submission Claim Entry Template are displayed in Figure 2.0.3. Headers and segments are further explained throughout the user guide.

• The Claim Entry Template has both optional and required fields. Non-editable fields are unavailable (grayed) and cannot be populated. Mandatory or required fields are noted with a red asterisk following the field name.

4. In the Transaction Count list, select a transaction count. The transaction count must match the number of claims being submitted. The value for this can be 1, 2, 3, or 4. See Figure 2.0.4.

Figure 2.0.4 – Request Header Segment

• The Bin Number and Processor Control Number are pre-populated.

5. The Service Provider ID Qualifier and Service Provider ID boxes populate based on the provider ID you selected from the list on the Service Provider List page.

• The Service Provider ID and Qualifier should not be changed once you are in the template. The ID and Qualifier populate from the selection list.

6. In the Date Filled box, enter the date filled in MM/DD/YYYY format. Refer to Figure 2.0.4. You can type it in or use the calendar to select the appropriate date. See Figure 2.0.5.



Figure 2.0.5 – Calendar

• To use the Calendar, click the list to select a month, click the list to select the appropriate year, and click the appropriate day.

7. In the Date of Birth list, enter or select the date using the Calendar. See Figure 2.0.6.

Figure 2.0.6 – Request Patient Segment

8. In the Sex Code list, select the gender code. Refer to Figure 2.0.6.

0 – Unknown

1 – Male

2 – Female

9. The Pregnancy Indicator field is not required. If applicable, from the Pregnancy Indicator list, select 1 – Not Pregnant or 2 – Pregnant. Refer to Figure 2.0.6.

10. In the Cardholder ID Number box, enter the cardholder ID number. See Figure 2.0.7.



Figure 2.0.7 – Request Insurance Segment

11. In the Cardholder First Name field, enter the member’s first name. Refer to Figure 2.0.7.

12. In the Cardholder Last Name field, enter the member’s last name. Refer to Figure 2.0.7.

• The Group Number field pre-populates with KYMEDICAID.

13. In the Prescription Reference Number box, enter the Rx number. See Figure 2.0.8.

• The Prescription Reference Number Qualifier pre-populates with 1 – Rx Billing.



Figure 2.0.8 – Request Claim Segment

14. In the Product/Service ID Qualifier list, select a product/service ID qualifier. This field pre-populates with 03 – NDC. Refer to Figure 2.0.8.

15. In the Product/Service ID box, enter the product/service ID (NDC number of the product on the claim). Refer to Figure 2.0.8.

• If the NDC is unknown, a search may be performed by clicking Search

. A Product/Service ID Qualifier is required before proceeding.

• For compound claims, in the Product/Service ID Qualifier list, select 00 – Not Specified and in the Product/Service ID box, type 0.

16. In the Quantity Dispensed box, enter the quantity. Refer to Figure 2.0.8.

17. In the New/Refill Code box, enter 0 for a new prescription or the appropriate number if the prescription is a refill. Refer to Figure 2.0.8.

18. In the Days Supply box, enter the number of days. Refer to Figure 2.0.8.



19. In the Compound Code list, select whether or not the prescription is for a compound. Refer to Figure 2.0.8.

20. Select the appropriate code from the Dispense As Written list. Refer to Figure 2.0.8.

0 – No Product Selection Indicated

1 – Substitution Not Allowed by Prescriber

2 – Substitution Allowed – Patient Requested Product Dispensed

3 – Substitution Allowed – Pharmacist Selected Product Dispensed

4 – Substitution Allowed – Generic Drug Not In Stock

5 – Substitution Allowed-Brand Drug Dispensed as a Generic

6 – Override

7 – Substitution Not Allowed – Brand Drug Mandated by Law

8 – Substitution Allowed – Generic Drug Not Available in Marketplace

9 – Substitution Allowed By Prescriber but Plan Requests Brand - Patient's Plan Requested Brand Product To Be Dispensed

21. In the Date Prescription Written box, enter the date the prescription was written. You can type it in or use the calendar to select the appropriate date. Refer to Figure 2.0.8.

22. In the Number Refills Authorized box, enter the appropriate number. Refer to Figure 2.0.8.

23. Select the origin of the prescription from the Prescription Origin Code list. Refer to Figure 2.0.8.

0 – Not Specified

1 – Written Prescription

2 – Telephone Prescription

3 – Electronic

4 – Facsimile

5 – Pharmacy

24. In the Unit of Measure list, select the appropriate unit. Refer to Figure 2.0.8.

25. If applicable, select the appropriate code from the Submission Clarification list. See Figure 2.0.9.



Figure 2.0.9 – Submission Clarification Code Count Segment

• If there are multiple Submission Clarification codes, click the arrow pointing right to obtain an additional Submission Clarification Code Count Segment. Refer to Figure 2.0.9.

• If the claim is for a compound, select 8 – Process Compound for Approved Ingredients from the Submission Clarification list. The “8” allows the claim to continue processing if at least one ingredient is covered.

26. In the Prescriber ID box, enter the prescriber ID. See Figure 2.0.10.

Figure 2.0.10 – Request Prescriber Segment

• The Prescriber ID Qualifier pre-populates with National Provider Identifier (NPI).

27. If needed, enter the prescriber’s last name in the Prescriber Last Name box and enter the prescriber’s first name in the Prescriber First Name box. These fields are not required.

28. To view the COB Segment, click Show to the right of Request_COB_Segment. See Figure 2.0.11.

Figure 2.0.11 – Request_COB_Segment

29. In the Other Payer Coverage Type list, select the other payer coverage type. See Figure 2.0.12.



Figure 2.0.12 – Request COB Segment

30. If the COB Other Payment Count Segment needs to be completed, the following fields need to be completed:

a. In the Other Payer ID Qualifier list, select 99-Other.

b. In the Other Payer ID box, enter the other payer ID.

c. In the Other Payer Date box, enter or use the Calendar to select the other payer date.

• If the patient has multiple Other Payment Count segments, click the arrow pointing right to obtain a blank window. Refer to Figure 2.0.12.

d. In the Other Payer Amount Paid Qualifier list, select 08-Sum of all Reimbursement. See Figure 2.0.13.

Figure 2.0.13 – Other Payer Amount Paid Count Segment

e. In the Other Payer Amount Paid box, enter the other payer amount paid.



• The Request COB and Other Payer Segments should only be populated if other coverage exists and is being billed for the patient.

• If the patient has multiple Other Payer Amt Paid Count segments, click the arrow pointing right to obtain a blank window. Refer to Figure 2.0.13.

f. In the Other Payer Reject Code list, select the other payer reject code. See Figure 2.0.14.

Figure 2.0.14 – Other Payer Reject Count Segment

• If the patient has multiple Other Payer Reject Count segments, click the arrow pointing right to obtain a blank window. Refer to Figure 2.0.14.

g. In the Other Payer-Patient Responsibility Amount Qualifier list, select the other payer reject code and enter the amount in the Other Payer-Patient Responsibility Amount box. See Figure 2.0.15.

Figure 2.0.15 – Other Payer-Patient Responsibility Amount Count Segment

31. If applicable, in the Benefit Stage Qualifier list, select the other payer reject code and enter the amount in the Benefit Stage Amount box. See Figure 2.0.16.



Figure 2.0.16 – Benefit Stage Count Segment

32. The DUR PPS CD Counter Segment should only be populated if there is a DUR Encounter with the claim being submitted. To view the DUR PPS CD Counter Segment, click Show to the right of Request_DUR_Segment. See Figure 2.0.17.

Figure 2.0.17 – Request_DUR_Segment

33. The DUR_PPS_CD_Counter Segment displays. See Figure 2.0.18.

Figure 2.0.18 – DUR PPS CD Counter Segment

• The service codes must be chosen by the dispensing pharmacists and noted on the Universal Claim Form (UCF).

• If there is more than one DUR PPS CD, click the arrow pointing right to obtain a blank window. Refer to Figure 2.0.18.

a. In the Reason for Service Code list, select the reason for service code.

b. In the Professional Service Code list, select the professional service code.

c. In the Result of Service Code list, select the result of service code.

34. In the Ingredient Cost Submitted box, enter the ingredient cost submitted. See Figure 2.0.19.



Figure 2.0.19 – Request Pricing Segment

35. The Dispensing Fee Submitted and Incentive Amount Submitted fields are optional.

36. In the Usual and Customary Charge box, enter the usual and customary charge.

37. In the Gross Amount Due box, enter the gross amount due.

38. If the claim is for a compound, the following fields in the Compound Segment must be completed. To access the Compound Segment, click Show to the right of Request_Compound_Segment. See Figure 2.0.20.

Figure 2.0.20 – Request_Compound_Segment

39. The Compound Segment and Compound Ingredient Component Count Segments display. See Figure 2.0.21.

Figure 2.0.21 – Request Compound and Compound Ingredient Component Count Segments



a. In the Compound Dosage Form Description Code list, select the compound dosage form description code.

b. In the Compound Dispensing Unit Form Indicator list, select the compound dispensing unit form indicator.

c. In the Compound Product ID Qualifier list, select the compound product ID qualifier.

d. In the Compound Product ID box, enter the compound product ID.

e. In the Compound Ingredient Quantity box, enter the ingredient quantity.

f. In the Compound Ingredient Drug Cost box, enter the ingredient drug cost.

g. In the Compound Ingredient Basis of Cost Determination list, select the basis of cost determination for the ingredient.

h. Enter additional ingredients by clicking the right arrow to enter the next ingredient(s) and completing all required fields.

40. The Diagnosis CD Count Segment is typically not used. To access the Diagnosis CD Count Segment, click Show to the right of Request_Clinic_Segment. See Figure 2.0.22.

Figure 2.0.22 – Request_Clinic_Segment

41. The Diagnosis_CD_Count_Segment displays. If applicable, in the Diagnosis Code Qualifier list, select the diagnosis code qualifier and enter the diagnosis code in the Diagnosis Code box. See Figure 2.0.23.

Figure 2.0.23 – Diagnoses CD Count Segment

42. To submit the claim, click Submit Claim(s).



2.1 Submitting a Multi-Claim Transaction

Up to four claims can be submitted with one transaction. To submit a multi-claim transaction, please use the following steps:

1. Click the right facing arrow located at the bottom of the page above the Submit Claim(s) button. Another request transmission segment appears. See Figure 2.1.1.

Figure 2.1.1 –Claim Entry template

2. Complete the additional segment with claim information.

3. Click Submit Claim(s) to process the additional claim (s). The Claim Submission Response window appears. See Figure 3.0.1.



• The Transaction Count box must match the number of claims.

• When submitting multiple claims in one transaction, the Patient, Prescriber, and Service Provider must be the same.





3.0 Claim Submission Response The Claim Response tab shows the status of the claim once submitted. If the claim did not “pay,” the Reject Code(s) and descriptions are listed on the Claim Response window.

The fields that appear on the Claim Response window vary depending on why the claim is actually rejecting or denying. See Figure 3.0.1.

Figure 3.0.1 – Claim Submission Response



• Click the Claim Data tab to make changes to the submitted claim that denied or rejected.



4.0 Searching for a Claim To search for a claim, please use the following steps:

1. From the Service Provider window, select the provider ID from the list. See Figure 4.0.1.

Figure 4.0.1 – Web Claim Submission, Service Provider Window

2. Click Select. The Selection window appears allowing you to select perform a Claim Search or select a Claim Template. See Figure 4.0.2.

Figure 4.0.2 – Web Claims Submission Selection Window

• To change Providers, click the Service Provider hyperlink and the Change Provider window appears.



3. In the Cardholder ID box, enter the cardholder ID.

4. In the Date of Service box, enter or use the Calendar to select the date of service.

• All dates should be entered MM/DD/YYYY.

• Wherever the Calendar button appears, you can use it to populate the date field. See Figure 4.0.3.

Figure 4.0.3 – Calendar

• To use the Calendar, click the Month list to select a month or click the Year list and select the year, type the appropriate year, and click the appropriate day.

5. Click Search. The Adjudicated Claims Search Result window appears. See Figure 4.0.4.



Figure 4.0.4 – Adjudicated Claims Search Result Window

• To view the claim, click the Internal Claim Number. The Claim Information window appears. See Figure 4.0.5.

• To change the results, check or clear the check boxes in the Show Columns area.



Figure 4.0.5 – Claim Information Window

• To return to the Adjudicated Claims Search Results window, click Close Window.

• To print the claim information, click the Printer icon.



4.1 Resubmitting a Claim

To resubmit a claim, please use the following steps:

1. Search for a particular claim. Refer to Section 4.0 – Searching for a Claim to see how to search for a particular claim. See Figure 4.1.1.

Figure 4.1.1 – Search Window

2. Enter the search parameters, click Search, and the Adjudicated Claims Search Result window appears. See Figure 4.1.2.



Figure 4.1.2 – Adjudicated Claims Search Result Window

3. Click the Resubmit icon in the Action column of the Adjudicated Claims Search results. See Figure 4.1.3.

Figure 4.1.3 –Resubmit Icon

4. The Claim Data window appears with the information from the selected entry pre-populated. See Figure 4.1.4.



Figure 4.1.4 – Re-Submit Claim Data Window



5. Make any changes and click Re-Submit Claim(s). The Claim Response window appears. Refer to Section 4.0 – Claim Submission Response.



5.0 Glossary Adjudicate – Magellan Medicaid Administration runs claim data through a series of edits. Based on client guidelines, the claims data must pass specified edits in order to return a favorable (paid) response. If the edits cannot be passed, Magellan Medicaid Administration will return a denied response. The process of determination is called the adjudication process.

Algorithm – Formula used to determine reimbursement.

Allowed Amount – The total amount payable for a claim before any deduction (i.e., co-pay and or deductible) determined by the program benefits.

Average Wholesale Price (AWP) – The suggested wholesale price of a drug obtained from the manufacturer/labeler or from a price survey of wholesalers.

Bank Information Number (BIN) – A National Council for Prescription Drug Programs (NCPDP) assigned number used to track payees.

Benefit – The amount to the payee that may be paid by the third-party administrator or insurance company.

Brand Drug – The drug name that appears on the package label. A product that is available by only one manufacturing source or under patent protection (trademark) by one manufacturer.

Cardholder – The person who is receiving the benefits of the program. Typically, we use the term “member” or “subscriber” to refer to persons in a commercial-type program. Persons in a Medicaid-type account are usually referred to as “recipients.”

Client – Typically, we use the term “client” to describe the State/or State user.

CII – A drug that has been assigned a Drug Enforcement Administration (DEA) Code value of “2,” indicating high abuse potential. No refill allowed.

Compound Drug – A compound is made up of two or more ingredients or drugs. Typically, compound drugs are processed differently than noncompound drugs.

Controlled Substance – A drug that is determined by the Drug Enforcement Administration (DEA) to be subject to possible abuse. The DEA applies a numeric schedule indicating the different degrees of possible abuse.

Coordination of Benefits (COB) – A method of integrating benefits payable under more than one group, not to exceed 100 percent of the claim. COB determines the order in which multiple carriers pay benefits.

Co-pay – The amount that the member/cardholder must pay toward the entire cost of the prescription claim. This may be a fixed dollar amount or a percentage amount. It may vary



depending on whether the drug is a brand or a generic and may be influenced by the selected Dispense As Written (DAW) code.

Date of Service (DOS) – The date the prescription is dispensed to the member/recipient. This is also known as DOS or refill date.

Days’ Supply – The duration (in number of days) that a prescription should last. Most plans have a maximum days’ supply limit per claim.

Deductible – Amount the member must pay before they are eligible for program benefits.

Denied – “Denial” refers to a claim status. Claim denials occur if edits are not resolved during claims processing.

DESI – FDA Drug Efficacy Study Implementation (DESI) program indicator declaring a less-than-effective drug.

Department of Justice (DOJ) Price – Fair market price set by the Department of Justice.

Dispensed as Written (DAW) – It is also known as the “Product Selection Code.” The code indicates whether or not the prescriber’s instructions regarding generic substitutions are allowed. Use of the different DAW codes may affect the inclusion of certain products and/or co-pay in claims processing.

Dispensing Fee – The amount, in addition to the ingredient price, paid to the pharmacy for the actual dispensing of the prescription drug.

Dispensing Limits – The amount of therapy (quantity and days' supply) allowed for a specific benefit program.

Drug Efficacy Study Implementation (DESI) Drug – These are drugs that were introduced into the market as new drugs from 1938–1962 that were submitted for review by the National Academy of Sciences-National Research Council Drug Efficacy Study Group and still considered by the FDA as less than effective meeting their manufacturer’s claims. Most plans do not cover DESI drugs.

Drug Enforcement Administration (DEA) Code – The numeric code denoting the degree of abuse and federal control of the drug.

Drug Enforcement Administration (DEA) Number – Unique identification number assigned to a physician/pharmacy by the DEA. The number must accompany a prescription for a controlled substance. The format for this number is always two alphas followed by seven numeric (AANNNNNNN).

Drug Form – A drug form is the method by which a drug is administered. Some common forms include aerosol, vial, cream, syrup, needle, powder, lotion, oil, spray, capsule, tablet, elixir, solution, shampoo, etc.



Drug Utilization Review (DUR) – This is a method by which drug use/therapy is monitored against predesigned standards for utilization.

Durable Medical Equipment (DME) – Typically applies to supply-type products that traditionally are not billed as prescription pharmacy.

Effective Date – The date coverage goes into effect.

ePrescribing – ePrescriptions are computer-generated prescriptions created by your doctor and sent directly to your pharmacy.

Error Claim – A claim that does not go through the adjudication process. This means the provider is submitting a claim that is missing the required data elements.

Example: M/I Group Number

First DataBank (FDB) – FDB is a company that provides both standard and detailed drug-processing data to government and health care organizations. They also provide drug-pricing changes.

Formulary – A listing of covered drugs or products for a particular program.

Generic Differential – The difference between the calculated allowed amounts for the brand and the generic of the indicated products. In the case of a DAW of “2,” where the patient is requesting the brand, the generic differential may be assessed in addition to the co-pay amount.

Generic Drug – A drug considered to be therapeutically equivalent to the brand name drug but produced by other manufacturers. The generic drug is usually less expensive than the brand name drug. Once a drug has been formulated, the manufacturer will obtain a patent that will not expire for approximately 17 years. During the 17-year period, the drug is sold as a brand name drug, allowing the manufacturer to recoup most of the cost for research and development. After the patent expires, other manufacturers can duplicate the drug. The significant difference between a brand name drug and a generic drug is the components that hold the formula together. As a result, generics are graded and classified by how well they duplicate the brand name drug.

Generic Sequence Number (GSN) – A five-digit code that groups together all NDCs that have the same generic chemical composition in the same strength and form.

Gross Amount Due – The total prescription price or expected reimbursement from all sources.

Hardware – Consists of the physical equipment of a computer.

Example: Wires, disks, chips, circuit boards, etc.

HCFA 1500/CMS 1500 Form – A form developed for use typically with the processing of Durable Medical Equipment (DME).

HCIdea™ – The HCIdea™ product is a relational database containing prescriber DEA numbers, state licenses, National Provider Identifiers (NPIs), multiple addresses, and other prescriber



information. It obtains prescriber NPIs from the CMS National Plan and Provider Enumeration System (NPPES) only, the supplier of prescriber NPIs and primary data source. Providing NPPES data in a format useful for those processing Medicaid prescription drug claims solves a nagging problem for the prescription drug benefit industry, which in many cases has been unable to obtain the correct NPI for prescribers.

HIC3 – The specific therapeutic class of the selected drug and is the first three characters of the HICL.

HICL – A unique and randomly assigned six-character number providing a link from either an NDC or GCN sequence number record to the hierarchical ingredient list.

Hospice – A facility that treats terminally ill patients.

Host – A computer that allows users to communicate with other computers on a network.

Ingredient Cost – The submitted cost of the drug dispensed.

Innovator – This means that the manufacturer is the first to manufacture the drug.

Legend Drug – Any drug that requires a written prescription from a physician before it can be dispensed. It is also known as “Federal Legend.”

Lock-In – A recipient is “locked” into using an assigned pharmacy, physician, drug, and/or class of drugs.

Long-Term Care (LTC) – Typically used to denote a long-term facility. Claims processing requirements may differ for LTC processing versus regular retail claims processing.

Maintenance Drug – A medication that is taken to maintain wellness over long periods of time.

Example: High-blood pressure medicine

Managed Access Care Program (MAP) – Magellan Medicaid Administration pharmacists and technicians review and evaluate DUR criteria based on client guidelines. Criteria are established for use in the online adjudication process. Claims will deny if criteria are not met. The staff pharmacists and technicians evaluate and override requests on a case-by-case basis.

Managed Care – Any system of delivering health services in which care is delivered by a specific network of doctors and hospitals who agree to comply with the care approaches established by a care management process.

Mandatory Generic Program – A program requiring a generic substitution for brand drugs when the generic is available and the physician has not written “Brand Medically Necessary” on the script.

Mandatory Point-of-Sale – A claims submission program that requires that all claims be submitted online at Point-of-Sale (POS). Member/recipients are required to use a participating pharmacy and have their claims submitted online.



Manufacturer – Name of the company that produces the medication.

Maximum Allowable Cost or Change (MAC) Penalty – An amount used to determine a patient’s monetary responsibility for a prescription. The patient’s responsibility would be the difference between the cost of the brand name drug and the cost of the generic equivalent (plus co-payment, if any.)

Metric Decimal Quantity – The amount of tablets, capsules, grams, etc., prescribed by the doctor, including fractions or decimals.

Metric Quantity – The amount of tablets, capsules, grams, etc., prescribed by the doctor in whole numbers.

Multi-source – A drug that is produced by more than one manufacturer. Multi-source drugs have both a brand and therapeutically equivalent generic product.

National Association for the Board of Pharmacy (NABP) Number – A unique identification number assigned to every operating pharmacy. It is a seven-digit number. The first two numbers represent the state in which the pharmacy resides. This number is also referred to as the NCPDP number.

National Council for Prescription Drug Programs (NCPDP) – An organization that sets the standards for automated pharmacy claims processing. NCPDP developed a standard format for electronic claims submission between pharmacy providers, insurance carriers, and third party administrators. NCPDP standards encompass the data format and field content (field requirements and usage), the transmission protocol (specifications), and other telecommunication requirements.

National Drug Code (NDC) – Every drug is assigned an 11-digit NDC number. This includes over-the-counter (OTC) products as well as legend products. The 11-digit number represents 3 sections of information. The first 5 numbers represent the labeler or manufacturer. The next 4 digits represent the product code. The last 2 digits represent the package size.

National Provider Identifier (NPI) – A HIPAA Administrative Simplification Standard. It is a unique identification number for covered health care providers. It is a 10-position, intelligence-free numeric, meaning it does not carry over any state or specialty information.

Network – A network (switch) connects the pharmacy via telephone line to Magellan Medicaid Administration in order to process point-of-sale claims. When a provider submits a POS claim, the data is transmitted through the telephone line to a network (switch). The network captures and sorts the information. The network reads the processor control number then directs the claim to the claims processor. After Magellan Medicaid Administration adjudicates (processes) the claim, the appropriate response is sent back through the network to the provider.

Non-Participating Pharmacy – When a pharmacy is not part of the client’s pharmacy network.

Obsolete Date – The manufacturer-assigned termination date of an NDC, plus one year.



Out-of-Pocket (OOP) – Maximum amount of dollars the member/recipient is required to pay before receiving a 100 percent reimbursement.

Over-The-Counter (OTC) Drug – These are drugs that traditionally can be purchased without a doctor’s written prescription. Programs that allow reimbursement for OTC products may require a physician’s written script in order for claim reimbursement through the program.

Package Size – The labeled quantity provided by the manufacturer from which the pharmacist can dispense different amounts of medication.

Example: A patient takes a prescription to the pharmacy for 10 tablets of Tagament®. The pharmacist fills the prescription from a Tagament® package size containing 1,000 tablets.

Paid Amount – The amount paid by the insurance or third-party administrator to the payee.

Payment Methodology – A pricing or reimbursement formula by which claims are priced according to the program’s guidelines. Typically, there may be several different formulas and the system returns an allowed amount based on the lesser of the formulas calculated by price.

Pharmacy Network – Pharmacies (interconnected or interrelated) that are linked together in relation to payment disbursement.

Point-of-Sale (POS) – Describes a real-time online claims processing environment.

Practitioner Number – The practitioner number is a unique identification number assigned to prescribers. The number may be assigned by client but is typically the DEA number, State License Number, or NPI. Is also known as the “Physician ID.”

Preferred Drug List (PDL) – A list of preferred and non-preferred drugs. This list is determined by the client. Drugs are selected first by clinical efficacy and safety, and second by cost effectiveness.

Primary Carrier – The plan or insurance carrier that has the responsibility to pay first on incurred charges. The primary carrier always pays its normal liability without regard to other available coverage.

Prior Authorization (PA) – An override put into the system to allow a previously denied claim to pay. PAs must be issued within the guidelines designated by the client.

Processor Control Number (PCN) – A 10-digit number maintained by Magellan Medicaid Administration that is used for internal record keeping.

Provider Number – Magellan Medicaid Administration typically considers the pharmacy to be the provider. The pharmacy provider must be assigned a provider number for a specific client to process a claim. The format of the number varies by client. In some cases, the provider number is the pharmacy NABP number or NPI number.

Qualifier – A field that describes the information that will be populated in the corresponding field.



Example: Product/Service 03-NDC

Rebate – A price incentive returned to buyer as specified by a contractual agreement between the purchaser and manufacturer of drugs.

Recipient – Person receiving the benefits of a Medicaid-type program.

Remittance Advice (RA) – A summary listing of claims submitted to and received by Magellan Medicaid Administration. This summary is sent to participating providers.

Rx Number – A number assigned to a prescription by the provider to identify the claim.

Secondary Carrier – The plan or insurance carrier that pays after the primary plan has paid its benefits. The secondary carrier always considers any benefits paid by the primary carrier when calculating a payment.

Single-source – A drug that is produced by only one manufacturer. There is no therapeutically equivalent generic product available.

Software – A computerized program that is configured for the pharmacy provider to submit claims to Magellan Medicaid Administration in the appropriate format.

Software Vendor – A company that develops and sells pharmacy software packages to program users. The software vendors work hand-in-hand with the Magellan Medicaid Administration Provider Enrollment Department for program implementation.

Spend Down/QMB – Is to Medicaid what a deductible is to a commercial account. The amount the member must pay before he/she is eligible for program benefits.

Strength – The drug potency in units of grams, milligrams, percentages, etc.

Switch – Company that connects the pharmacy to the processor by way of validity checks prior to routing the claim’s data to the processor.

TCC – The Technical Call Center is staffed with pharmacy technicians and customer service representatives. This call center is also known as the Pharmacy Support Center. They will assist providers with calls of a technical nature such as providing DUR codes for provider level overrides or explaining an NCPDP denial code on a claim. In some instances, they will also take participant calls and complete prior authorizations.

Transaction Type – B1 – original, B2 – reversal, B3 – re-bill, E1 – captured claim.

Unit Dose – Indicates if a product is packaged by dose or bulk.

1–Not Unit Dose

2–Manufacturer Unit Dose

3–Pharmacy Unit Dose

4–Custom Packaging



Unit of Measure – A code that indicates how the drug should be measured per unit, when performing price calculations. Tablets and capsules should be measured by counting, liquids should be measured as milliliters, and solids should be measured as grams.

Universal Claim Form (UCF) – This is a standardized form created by NCPDP. Typically used by pharmacists for submitting paper claims.

Usual and Customary (U&C) – The dollar amount the pharmacy provider would charge a cash-paying customer to include any discounts for senior citizens, children, etc.

Version/Release – Identifies the format of the transaction sent or received.

Web PA – A web-based application developed by Magellan Medicaid Administration. It allows prescribers and their Delegated Administrators to enter prior authorizations for recipients and review the drug file to determine if a drug requires a prior authorization.

Web Claims Submission User Guide


6.0 Acronyms AWP – Average Wholesale Price

BIN – Bank Information Number

CMS – Centers for Medicare & Medicaid Services

COB – Coordination of Benefits

CPhT – Certified Pharmacy Technician

CRN – Control Reference Number

CSR – Customer Service Representative

DAW – Dispense As Written

DD – Drug-to-Drug

DEA – Drug Enforcement Administration

DESI – Drug Efficacy Study Implementation

DME – Durable Medical Equipment

DMS – Disposable Medical Supplies

DOB – Date of Birth

DOD – Date of Death

DOJ – Department of Justice

DOS – Date of Service

DUR – Drug Utilization Review

EAC – Estimated Acquisition Cost

ED – Erectile Dysfunction

EFT – Electronic Funds Transfer

EOB – Explanation of Benefits

ER – Overuse Precaution

EVS – Eligibility Verification System

FDA – Food and Drug Administration

FDB – First DataBank



FPL – Federal Poverty Level

FUL – Federal Upper Limit

GCN – Generic Code Number

GSN – GCN Sequence Number

GUI – Graphical User Interface

HCFA – Health Care Financing Administration (now CMS)

HD – High Dose

HIPAA – Health Information Portability and Accountability Act of 1996

HMO – Health Management Organization

ICD-9 – International Classification of Diseases, 9th Edition

ID – Ingredient Duplication

KDP – Kidney Disease Program

LTC – Long-Term Care

MAC – Maximum Allowable

MAP – Managed Access Program (Magellan Medicaid Administration Clinical Staff)

MC – Drug to Known Disease

MCO – Managed Care Organization

NABP – National Association for the Board of Pharmacy

NCPDP – National Council for Prescription Drug Programs

NDC – National Drug Code also National Data Corporation

NPI – National Provider Identifier

OBRA – Omnibus Budget Reconciliation Act

OTC – Over-the-Counter

PA – Prior Authorization

PAMC – Prior Authorization Medical Certification

PBM – Pharmacy Benefit Manager

PCN – Processor Control Number

PDL – Preferred Drug List



PDMS – Prescription Drug Management System

PDP – Preferred Drug Program

PG – Pregnancy Contradiction

PHI – Personal Health Information

POS – Point-of-Sale

PP – Plan Protocol

PRN – Prescription Reimbursement Network

ProDUR – Prospective Drug Utilization Review

QMB – Qualified Medicare Beneficiary

RetroDUR – Retrospective Drug Utilization Review

SR – Prerequisite Drug Therapy

SSN – Social Security Number

TD – Therapeutic Duplication

TIN – Tax Identification Number

TPA – Third-Party Administrator

TPL – Third-Party Liability

UCF – Universal Claim Form

WAC – Wholesale Actual Cost

WCS – Web Claims Submission





7.0 Index B

Bin Number, 8

C

Claim Segment, 11

Claim Template, 25

Clinic Segment, 18

COB Segment, 13, 14

Benefit Stage Count Segment, 16

Other Payer Amount Paid Count Segment, 14

Other Payer-Patient Responsibility Amount Count Segment, 15

Compound

Compound Segment, 17

Submission Clarification Code, 13

D

Date Prescription Written, 12

Diagnosis CD Count Segment, 18

Dispense As Written, 12

Drug Search, 11

DUR PPS CD Counter Segment, 16

H

Header Segment, 8

I

Insurance Segment, 10

M

Multiple Claims, 20

N

NDC, 11

NPI, 13

Number Refills Authorized, 12

O

Other Payer Coverage Type, 14

P

Patient Segment, 9

Payer Specification, 4

Pregnancy Indicator, 9

Prescriber Segment, 13

Prescription Origin Code, 12

Prescription Reference Number, 10

Print, 28

Processor Control Number, 8

Product/Service ID, 11

Provider, 37

R

Request Pricing Segment, 17

Response

Claim, 23

Resubmit

Claim, 29, 30

S

Search

Claim, 25, 27



Service Provider

selection, 6

Service Provider ID, 8

Sex Code, 9

Submission Clarification, 12, 13

T

Template, 7

Trial Adjudication, 7

U

Universal Claim Form, 16

Documents

Kentucky Web Claims Submission User Guide...Jun 26, 2014 · Kentucky Web Claims Submission User Guide Confidential and Proprietary Page 4 1.0 Introduction The Web Claims Submission