Free Noncompound Drug Claim, F13072 - Wisconsin

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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13072A (10/08)

STATE OF WISCONSIN HFS 106.03(1), Wis. Admin. Code

ForwardHealth requires certain information to authorize and pay for medical services provided to eligible members. Although these claim instructions refer to ForwardHealth members, these instructions also apply to Wisconsin Medicaid, BadgerCare Plus, SeniorCare, and Wisconsin Chronic Disease Program (WCDP) members. Members 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[4], 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 Noncompound Drug Claim form is used by ForwardHealth and is mandatory when submitting paper claims for noncompound 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, 19, 21, 23, and 26, refer to the Online Handbook for tables and accepted values. ForwardHealth members receive an identification card upon being determined eligible. Always verify a member's eligibility 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. For Medicaid, BadgerCare Plus, and SeniorCare members, return form to: ForwardHealth Claims and Adjustments 6406 Bridge Rd Madison WI 53784-0002 For Wisconsin Chronic Disease Program members, return form to: ForwardHealth PO Box 6410 Madison WI 53716-0410 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.


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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. SECTION III -- CLAIM INFORMATION Element 8 -- Prescriber Number Enter a valid NPI. The NPI is a new 10-digit number that is 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., Wisconsin 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. When billing unit dose (UD) services, the last date of service in the billing period must be entered. 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 -- NDC Enter the 11-digit National Drug Code (NDC) or the ForwardHealth-assigned 11-digit procedure code for the item being billed. (Use the NDC indicated on the product.) Element 13 -- Days' Supply Enter the days' supply of medication that has been dispensed 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 14 -- Qty Enter the metric decimal quantity in the specified unit of measure according to the ForwardHealth Drug File. Quantities billed should be rounded to two decimal places (i.e., nearest hundredth). Element 15 -- UD Enter one of the following National Council for Prescription Drug Programs (NCPDP) single-numeric indicators when billing for UD drugs and non-unit dose drugs. (This field is required for all pharmacy claims.) Element 16 -- Prescription Number Enter the prescription number. Each drug billed must have a unique prescription number. Element 17 -- DAW Enter the appropriate one-digit NCPDP dispense as written (DAW) code. Element 18 -- Drug Description (Optional) Element 19 -- Pt LOC Enter the appropriate two-digit NCPDP patient location code for each drug billed. Element 20 -- Diagnosis Code This element is required when billing for a drug for which ForwardHealth requires a diagnosis or when billing for Pharmaceutical Care (PC) services. If the diagnosis of the drug is different from that of the PC services, enter the diagnosis code of the drug from the International Classification of Diseases, Ninth Revision, Clinical Modification coding structure. Enter all digits of the diagnosis code, including the preceding zeros.


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Element 21 -- Level of Effort This element is required when billing for PC services. Refer to the Drug Utilization Review and Pharmaceutical Care section of the Online Handbook for PC information. Enter the NCPDP code from the following list that corresponds with the time required to perform the PC service. Element 22 -- Reason for Service This element is required when billing for Drug Utilization Review (DUR) or PC services. Refer to the Drug Utilization Review and Pharmaceutical Care section of the Online Handbook for DUR and PC information and applicable PC values. Element 23 -- Professional Service This element is required when billing for DUR or PC services. Refer to the Drug Utilization Review and Pharmaceutical Care section of the Online Handbook for DUR and PC information and applicable PC values. Element 24 -- Result of Service This element is required when billing for DUR or PC services. Refer to the Drug Utilization Review and Pharmaceutical Care section of the Online Handbook for DUR and PC information and applicable PC values. Element 25 -- Sub Clar Code Enter NCPDP submission clarification code "2" to indicate repackaging. Element 26 -- Other Coverage Code ForwardHealth is usually the payer of last resort for program-covered services. (Refer to the Coordination of Benefits section of 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 27 -- Charge Enter the total charges for this claim. Element 28 -- Other Coverage Amount When applicable, enter the amount paid by commercial health insurance. This is required when the OC code in Element 26 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 29 -- Patient Paid Amount When applicable for 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 an expected copayment for Wisconsin Medicaid, BadgerCare Plus, or SeniorCare. Element 30 -- Net Billed Enter the balance due by subtracting the OC amount and the patient paid amount from the amount in Element 27. Element 31 -- 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.