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© 2011, Magellan Medicaid Administration, Inc. All Rights Reserved
Fourth Quarter, 2011
QUICK NOTES
If a South Carolina Beneficiary has
Medicare Part B as their primary
insurance carrier, enter carrier code
90798 when submitting the claim to SC
Medicaid for secondary payment.
Please ensure the correct Medicaid ID
Number is used when submitting
claims.
HOW TO REQUEST A MAC REVIEW
If you disagree with the Maximum
Allowable Cost (MAC), you may appeal
by completing the form at this link:
http://southcarolina.fhsc.com/Downlo
ads/provider/SCRx_MAC_Price_Resear
ch_Request_Form.doc
RESOURCES
To obtain information from the SC
Department of Health and Human
Services, visit their website at
http://www2.scdhhs.gov/
For assistance with beneficiary or
prescriber eligibility, call the Pharmacy
Services Department at 1-803-898-
2876.
To receive Medicaid bulletins by e-
mail, send your e-mail address and
contact information to
To locate a Prescriber’s NPI, visit the
NPPES website at
https://nppes.cms.hhs.gov/NPPES/Wel
come.do.
To view the 2012 D.0 Payer
Specifications, visit our website at
http://southcarolina.fhsc.com/Downlo
ads/provider/SCRx_Payer_Specs_2012
0101.pdf
BLUE CROSS
Effective November 1, 2011
administered by Blue Cross Blue Shield of South Carolina (BCBSSC)
BCBSSC will perform the following services on behalf the South Carolina Department of Health and
Human Services (SCDHHS)
� Verification
Information Management System (MMIS);
� Management of the Health Insurance Premium Payment (HIPP) program;
� Support services to the retro Medicare, retro health and pay and cha
invoices;
� Cash receipts for provider, insurer, and beneficiary refunds to the Medicaid program, to include
credit balance reviews and collections from inactive provider accounts;
� Support services for the Casualty and Estate R
You may contact BCB
and fax numbers, please click on the link to the Medicaid Bulletin
http://southcarolina.fhsc.com/Downloads/provider/Bulletin_20111007.pdf
WHOLESALE
Effective with dates of service on or after
Wholesale Acquisition Cost (WAC) plus 0.8% in their
determining the
decrease change in annual aggre
current rate of Average Wholesale Price (AWP) minus 16%.
PRICE INCREASE FOR
Effective for dates of service on or after
to the current Average Who
$2,192.89 and t
Academy of Pediatrics (AAP) 2009 guidel
please click on the link
http://southcarolina.fhsc.com/Downloads/provider/Bulletin_20111013.pdf
TOLL FREE
Effective December 31, 2011, the SC Department of Health and Human Services’ (SCDHHS) toll free
eligibility verification li
information via the free SCDHHS Web Tool, an internet based website available to all SC providers
hours a day at no charge.
please call the Provider Service Center at 1
register for training on the system and to
an ID, you may view the Web
NCPDP
As of January 1, 2012,
be in effect
ved.
ROSS BLUE SHIELD OF SC TO ADMINISTER MIVS CONTRACT
November 1, 2011, the Medicaid Insurance Verification Services (MIVS) contract will be
administered by Blue Cross Blue Shield of South Carolina (BCBSSC).
BCBSSC will perform the following services on behalf the South Carolina Department of Health and
Human Services (SCDHHS):
Verification and maintenance of Medicaid beneficiary primary health insurance in the Medicaid
Information Management System (MMIS);
Management of the Health Insurance Premium Payment (HIPP) program;
Support services to the retro Medicare, retro health and pay and cha
invoices;
Cash receipts for provider, insurer, and beneficiary refunds to the Medicaid program, to include
credit balance reviews and collections from inactive provider accounts;
Support services for the Casualty and Estate Recovery departments of SCDHHS.
You may contact BCBSSC at 888-289-0709 option 5. For further contact information such as addresses
and fax numbers, please click on the link to the Medicaid Bulletin below:
http://southcarolina.fhsc.com/Downloads/provider/Bulletin_20111007.pdf
HOLESALE ACQUISITION COST (WAC)
Effective with dates of service on or after November 1, 2011, South Carolina Medicaid will include
Wholesale Acquisition Cost (WAC) plus 0.8% in their Basis for Payment, “lesser than logic” in
determining the reimbursement for Medicaid prescriptions. This change is not expected to result in a
decrease change in annual aggregate expenses, as WAC plus 0.8% will generally be equivalent to the
current rate of Average Wholesale Price (AWP) minus 16%.
NCREASE FOR SYNAGIS® INJECTABLE
Effective for dates of service on or after October 15, 2011, SCDHHS will increase
to the current Average Wholesale Price (AWP) minus 18%. The new rates for 100mg v
$2,192.89 and the 50mg vial will increase to $1,161.31. SCDHHS will continue to utilize the American
Academy of Pediatrics (AAP) 2009 guidelines for the administration of Synagis®.
please click on the link to the Medicaid Bulletin below:
http://southcarolina.fhsc.com/Downloads/provider/Bulletin_20111013.pdf
REE ELIGIBILITY VERIFICATION LINE (IVRS) TO BE RETIRED
Effective December 31, 2011, the SC Department of Health and Human Services’ (SCDHHS) toll free
eligibility verification line (1-888-809-3040) will no longer be available. Providers may access the same
information via the free SCDHHS Web Tool, an internet based website available to all SC providers
hours a day at no charge. Providers must have an ID to access the Web Tool.
please call the Provider Service Center at 1-888-289-0709 and select Option 1 by December 12, 2011 to
register for training on the system and to obtain a SCDHHS Web Tool ID.
an ID, you may view the Web Tool by clicking on the following link: https://webclaims.scmedicaid.com
VERSION D.0
As of January 1, 2012, once D.0 is adopted, the following changes for pharmacy claims submissions will
be in effect.
Page 1 of 3
Volume 2, Number 3
CONTRACT
surance Verification Services (MIVS) contract will be
BCBSSC will perform the following services on behalf the South Carolina Department of Health and
and maintenance of Medicaid beneficiary primary health insurance in the Medicaid
Management of the Health Insurance Premium Payment (HIPP) program;
Support services to the retro Medicare, retro health and pay and chase benefit recovery
Cash receipts for provider, insurer, and beneficiary refunds to the Medicaid program, to include
credit balance reviews and collections from inactive provider accounts;
partments of SCDHHS.
For further contact information such as addresses
http://southcarolina.fhsc.com/Downloads/provider/Bulletin_20111007.pdf
arolina Medicaid will include
Basis for Payment, “lesser than logic” in
This change is not expected to result in a
gate expenses, as WAC plus 0.8% will generally be equivalent to the
, SCDHHS will increase the rate for Synagis®
The new rates for 100mg vial will increase to
SCDHHS will continue to utilize the American
e administration of Synagis®. For further details,
http://southcarolina.fhsc.com/Downloads/provider/Bulletin_20111013.pdf
ETIRED
Effective December 31, 2011, the SC Department of Health and Human Services’ (SCDHHS) toll free
Providers may access the same
information via the free SCDHHS Web Tool, an internet based website available to all SC providers 24
an ID to access the Web Tool. If you do not have an ID,
0709 and select Option 1 by December 12, 2011 to
obtain a SCDHHS Web Tool ID. For those providers who have
https://webclaims.scmedicaid.com.
the following changes for pharmacy claims submissions will
Magellan Medicaid Administration
CONTACT PROVIDER RELATIONS
To supplement those services provided by the Technical Call Center, the Provider Relations staff has established an email box
inquiries during normal business hours. Should you have a claim processing concern, contact us at
MANDATORY FIELDS
Submission of the following fields will become mandatory.
Field Name NCPDP Field #
Patient First Name 310-CA D.0 claims submitted without the patient’s first name will deny as “M/I Patient First
Name”.
Patient Last Name 311-CB D.0 claims submitted without the patient’s last name will deny as “M/I Patient Last
Name”.
Gender Code 305-C5 D.0 claims submitted without the gender code will deny as “M/I Patient Gender Code”.
Date of Birth 304-C4 D.0 claims submitted
Gross Amount Due 430-DU D.0 claims submitted with a Gross Amount Due (GAD) less than or equal to $0.00 will
deny as “M/I Gross Amount Due”.
Route of Administration 995-E2 NOTE: For compound
Administration will deny as “M/I Route of Administration”.
PATIENT LOCATION / PATIENT RESIDENCE FIELDS
The “Patient Location” field will be eliminated once D.0 becomes effective and will be replaced
384-4X). The values accepted in this field are as follows:
Patient Residence
Home
Nursing Facility
Assisted Living Facility
Hospice
The use of Patient Location value “10” (Outpatient)
providers, those products for which SC DHHS allows pharmacy providers to bill for physician administered drugs will be exclud
Authorization (PA) requirement.
COB CLAIMS
Upon adoption of D.0 on January 1, 2012, the Other Coverage Code value “7” will no longer be accepted. Utilize the chart belo
which Other Coverage Code value is appropriate.
OCC Use this value if…
2 Primary payer makes payment
3 Primary payer does not cover the drug
~OR~
Primary payer denied the claim as the
Beneficiary’s coverage was not effective on
the date of service
4 Primary payer’s total payment is applied to
the Beneficiary’s Deductible or Copayment
To supplement those services provided by the Technical Call Center, the Provider Relations staff has established an email box
normal business hours. Should you have a claim processing concern, contact us at [email protected]
of the following fields will become mandatory.
Comments
D.0 claims submitted without the patient’s first name will deny as “M/I Patient First
Name”.
D.0 claims submitted without the patient’s last name will deny as “M/I Patient Last
Name”.
D.0 claims submitted without the gender code will deny as “M/I Patient Gender Code”.
D.0 claims submitted without the date of birth will deny as “M/I Birth Date”.
D.0 claims submitted with a Gross Amount Due (GAD) less than or equal to $0.00 will
deny as “M/I Gross Amount Due”.
NOTE: For compound claims only. D.0 claims submitted without the Route of
Administration will deny as “M/I Route of Administration”.
IELDS
will be eliminated once D.0 becomes effective and will be replaced with the “Patient Residence”
The values accepted in this field are as follows:
Patient Residence Value
1
Nursing Facility 3
Assisted Living Facility 4
11
The use of Patient Location value “10” (Outpatient) will cease with the adoption of D.0. To decrease the administrative burden on pharmacy
providers, those products for which SC DHHS allows pharmacy providers to bill for physician administered drugs will be exclud
Upon adoption of D.0 on January 1, 2012, the Other Coverage Code value “7” will no longer be accepted. Utilize the chart belo
Additional fields to complete…
Field name NCPDP #
Other Payer Amount Paid 431-DV Enter payer’s payment amount
Other Payer Patient Responsibility
Amt
352-NQ Enter patient’s liability
Beneficiary’s coverage was not effective on
Other Payer Reject Code 472-6E Enter payer’s reject reason
Primary payer’s total payment is applied to
the Beneficiary’s Deductible or Copayment
Other Payer Patient Responsibility
Amt
352-NQ Enter patient’s liability
Fourth Quarter, 2011
To supplement those services provided by the Technical Call Center, the Provider Relations staff has established an email box to address your
Page 2 of 3
D.0 claims submitted without the patient’s first name will deny as “M/I Patient First
D.0 claims submitted without the patient’s last name will deny as “M/I Patient Last
D.0 claims submitted without the gender code will deny as “M/I Patient Gender Code”.
without the date of birth will deny as “M/I Birth Date”.
D.0 claims submitted with a Gross Amount Due (GAD) less than or equal to $0.00 will
. D.0 claims submitted without the Route of
with the “Patient Residence” field (NCPDP field #
To decrease the administrative burden on pharmacy
providers, those products for which SC DHHS allows pharmacy providers to bill for physician administered drugs will be excluded from the Prior
Upon adoption of D.0 on January 1, 2012, the Other Coverage Code value “7” will no longer be accepted. Utilize the chart below to determine
te…
Reason
Enter payer’s payment amount
Enter patient’s liability
Enter payer’s reject reason
Enter patient’s liability
Magellan Medicaid Administration
CONTACT PROVIDER RELATIONS
To supplement those services provided by the Technical Call Center, the Provider Relations staff has established an email box
inquiries during normal business hours. Should you have a claim processing concern, contact us at
PRESCRIPTION ORIGIN CODE
For D.0 transactions, claims submitted with a Prescription Origin Code (NCPDP field #: 419
Prescription Origin Code”. The accepted values for this field are as follows:
To supplement those services provided by the Technical Call Center, the Provider Relations staff has established an email box
normal business hours. Should you have a claim processing concern, contact us at [email protected]
For D.0 transactions, claims submitted with a Prescription Origin Code (NCPDP field #: 419-DY) value of “0-Unspecified” will deny as “
for this field are as follows:
Value Description
1 Written
2 Telephone
3 Electronic
4 Facsimile
5 Pharmacy
Fourth Quarter, 2011
To supplement those services provided by the Technical Call Center, the Provider Relations staff has established an email box to address your
Page 3 of 3
Unspecified” will deny as “M/I
