12/17/2023 0 Comments Bcbs timely filing limit 2016Preferred agents with clinical criteria attached to the medication and all non-preferred agents subject to the Preferred Drug List (PDL) Over-the-counter (OTC) drugs that are not a regular Health First Colorado program benefit.Non-preferred agents subject to the Preferred Drug List (PDL).A PAR approval does not override any of the claim submission requirements. Some claim submission requirements include timely filing, eligibility requirements, pursuit of third-party resources, and required attachments included. All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program. If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax.Īpproval of a PAR does not guarantee payment. Only members have the right to appeal a PAR decision. This letter identifies the member's appeal rights. In addition to stating whether the PAR has been approved or denied, a PAR denial notification letter is sent to members. Proposed rendering provider (if identified on the PAR).Notification of PAR approval or denial is sent to each of the following parties: All pharmacy PARs must be telephoned, faxed, or submitted via Real Time Prior Authorization via EHR, by the prescribing physician or physician's agent to the Pharmacy Benefit Manager Support Center. PARs are reviewed by the Department or the pharmacy benefit manager. The procedure to request a PAR and the medications that require a PAR are outlined in Appendix P - Pharmacy Benefit Prior Authorization Procedures and Criteria located in the Pharmacy Prior Authorization Policies section of the Department's website. Certain restricted drugs require prior authorization before they are covered as a benefit of the medical assistance program. Prior Authorization Request (PAR) Processĭrugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). Health First Colorado does not provide reimbursement for products by manufacturers that have not signed a rebate agreement unless the Department has made a determination that the availability of the drug is essential, such drug has been given 1-A rating by the Food and Drug Administration (FDA), and prior authorized. In addition, some products are excluded from coverage and are listed in the Restricted Products section. Drugs produced by companies that have signed a rebate agreement (participating companies) are generally a Health First Colorado program benefit but may be subject to restrictions. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements.įederal regulation requires that drug manufacturers sign a national rebate agreement with the Centers for Medicare and Medicaid Services (CMS) to participate in the state Medical Assistance Program. Providers should also consult the Code of Colorado Regulations (10 C.C.R. This pharmacy billing manual explains many of the Colorado Department of Health Care Policy & Financing's (the Department) policies regarding billing, provider responsibilities, and program benefits. Claim Reversal Rejected/Rejected Response.Claim Reversal Accepted/Rejected Response.Claim Reversal Accepted/Approved Response.Response Claim Reversal Payer Sheet Template.Request Claim Reversal Payer Sheet Template.NCPDP Version D.0 Claim Reversal Template.Claim Billing/Claim Rebill Rejected/Rejected Response.Claim Billing/Claim Rebill Accepted/Rejected Response.Claim Billing/Claim Rebill PAID (or Duplicate of PAID) Response.Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response.Response Claim Billing/Claim Rebill Payer Sheet Template.Electronic Claim Submission Requirements.Instructions for Completing the Pharmacy Claim Form.Delayed Notification to the Pharmacy of Eligibility.Delayed Processing by Third Party Payers.Ordering, Prescribing or Referring (OPR) Providers.EUA COVID-19 Antivirals Claim Requirements.Medication Prior Authorization Deferments.Temporary COVID-19 Policy and Billing Changes.Dispense As Written (DAW) Override Codes.Family Planning-Related Pharmacy Billing.Lost/Stolen/Damaged/Vacation Prescriptions.Incremental Fills and/or Prescription Splitting.Guidelines Used by the Department for Determining PAR Criteria.Prior Authorization Request (PAR) Process.
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