DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13073A (10/08)
STATE OF WISCONSIN HFS 106.03(1), Wis. Admin. Code
COMPOUND DRUG CLAIM COMPLETION INSTRUCTIONS
ForwardHealth requires certain information to authorize and pay for medical services provided to eligible Wisconsin Medicaid, BadgerCare Plus, and SeniorCare members. Members of ForwardHealth are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information should include, but is not limited to, information concerning enrollment status, accurate name, address, and member identification number (HFS 104.02, Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about ForwardHealth applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing prior authorization requests, or processing provider claims for reimbursement. The Compound Drug Claim form is used by ForwardHealth and is mandatory when submitting paper claims for compound drugs. Failure to supply the information requested by the form may result in denial of payment for the services. To avoid denial or inaccurate claim payment, use the following claim form completion instructions. Enter all required data on the claim form in the appropriate element. Do not include attachments unless instructed to do so. All elements are required unless "optional" or "not required" is indicated. For Elements 15, 17, and 18, refer to the Online Handbook for tables and accepted values. ForwardHealth members receive a ForwardHealth identification card upon being determined eligible. Always verify a member's enrollment before providing nonemergency services by using Wisconsin's Enrollment Verification System (EVS) to determine if there are any limitations on covered services and to obtain the correct spelling of the member's name. For questions regarding these instructions, providers may contact Provider Services at (800) 947-9627. Note: Submit claims for non-drug items, such as clozapine management services, disposable medical supplies, durable medical equipment, and enteral nutrition products, on the CMS 1500 claim form or the 837 Health Care Claim: Professional transaction using nationally recognized five-digit procedure codes. Return completed form to: ForwardHealth Claims and Adjustments 6406 Bridge Rd Madison WI 53784-0002 SECTION I -- PROVIDER INFORMATION Element 1 -- Name -- Provider Enter the name of the billing provider. Element 2 -- National Provider Identifier Enter the billing provider's National Provider Identifier (NPI). Element 3 -- Address -- Provider Enter the address, including the street, city, state, and ZIP+4 code of the billing provider. SECTION II -- MEMBER INFORMATION Element 4 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. Element 5 -- Name -- Member Enter the member's name from the member's ForwardHealth identification card. Use the EVS to obtain the correct spelling of the member's name. If the name or spelling of the name on the ForwardHealth card and the EVS do not match, use the spelling from the EVS. Element 6 -- Date of Birth -- Member Enter the member's date of birth in MM/DD/CCYY format (e.g., July 14, 1953, would be 07/14/1953). Element 7 -- Sex -- Member Enter "0" for unspecified, "1" for male, or "2" for female.
COMPOUND DRUG CLAIM COMPLETION INSTRUCTIONS F-13073A (10/08)
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SECTION III -- CLAIM INFORMATION Element 8 -- Prescriber Number Enter a valid NPI. The NPI is a new 10-digit number issued through the National Plan and Provider Enumeration System (NPPES), which was developed by the Centers for Medicare and Medicaid Services (CMS). The NPI will replace all payer-specific identification numbers (e.g., Medicaid provider numbers) on nationally recognized electronic transactions (also known as standard transactions). Element 9 -- Date Prescribed Enter the date shown on the prescription in MM/DD/CCYY format. Element 10 -- Date Filled Enter the date that the prescription was filled or refilled in MM/DD/CCYY format. Element 11 -- Refill Enter the refill indicator. The first two digits of the refill indicator is the refill being billed. This must be "00" if the date prescribed equals the date filled. The second element is the total refills allowed (e.g., the second refill of a six-refill prescription would be "02/06"). A non-refillable prescription would be "00/00." Enter "99" in the second element if the prescription indicates an unlimited number of refills. Element 12 -- Days' Supply Enter the days' supply of medication that has been prescribed for the member. This must be a whole number greater than zero (e.g., if a prescription is expected to last for five days, enter "5"). Element 13 -- Quantity Dispensed Enter the metric decimal quantity reflecting the total number of compound units dispensed. Note: The quantity may not always equal the total of compound ingredient quantities. Element 14 -- Prescription Number Enter the prescription number for the entire compound. Element 15 -- Pt Loc Enter the appropriate two-digit National Council for Prescription Drug Programs (NCPDP) patient location code for each drug billed. Element 16 -- Diagnosis Code This element is required when billing for any drug within the compound in which ForwardHealth requires a diagnosis. Enter a diagnosis code from the International Classification of Diseases, Ninth Revision, Clinical Modification coding structure in this element. Refer to the Pharmacy page of the ForwardHealth Online Handbook for more information about covered services and reimbursement. Element 17 -- Level of Effort Enter the NCPDP level of effort code from the following list that corresponds with the time required to prepare the compound.
COMPOUND DRUG CLAIM COMPLETION INSTRUCTIONS F-13073A (10/08)
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SECTION IV -- COMPOUND INGREDIENTS Indicate up to 25 compound ingredients using the following guidelines: Ingredient NDC Ingredient Quantity Ingredient Cost Indicate the 11-digit National Drug Code (NDC) for the item being billed. (Use the NDC indicated on the product.) Indicate the exact fractional metric quantity for the component ingredient used in the compound. Quantity billed should be rounded to two decimal places (i.e., nearest hundredth). Indicate the cost for the component ingredient used in the compound. The charge should represent the provider's usual and customary fee for the compound component.
Element 18 -- Other Coverage Code ForwardHealth is usually the payer of last resort for program-covered services. (Refer to the ForwardHealth Online Handbook for more information.) Prior to submitting a claim to ForwardHealth, providers are required to verify whether a member has other health insurance coverage (e.g., commercial health insurance, HMO, or Medicare). If a member has Medicare and other insurance coverage, the provider is required to bill both prior to submitting a claim to ForwardHealth. Enter one of the NCPDP other coverage (OC) codes that best describe the member's situation. Element 19 -- Charge Enter the total charges for this claim. Element 20 -- Other Coverage Amount When applicable, enter the amount paid by commercial health insurance. This is required when the OC code in Element 18 indicates "2." Note: Pharmacies may also include the Medicare-paid amount in this field for claims that fail to automatically crossover from Medicare to ForwardHealth within 30 days. Element 21 -- Patient Paid Amount When applicable on SeniorCare claims, enter the member's out-of-pocket expense due to OC, including Medicare Part B or D and/or commercial health insurance. Do not enter a member's expected copayment for Wisconsin Medicaid, BadgerCare Plus, or SeniorCare. Element 22 -- Net Billed Enter the balance due by subtracting the OC amount and the patient paid amount from the amount in Element 19. Element 23 -- Certification The provider or the authorized representative is required to sign this element. The month, day, and year the form is signed must also be entered in MM/DD/CCYY format. Note: The signature may be computer generated or stamped.