PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER. Required when other insurance information is available for coordination of benefits. Express Scripts Required when Basis of Cost Determination (432-DN) is submitted on billing. The following categories of members are exempt from co-pay: Effective July 1, 2022, the following changes occurred as it relates to family planning and family planning-related pharmacy benefits. 522-fm basis of reimbursement determination r 523-fn amount attributed to sales tax r 512-fc accumulated deductible amount r 513-fd remaining deductible amount r 514-fe remaining benefit amount r 517-fh amount applied to periodic deductible r 518-fi amount of copay r 52-fk amount exceeding periodic If there is more than a single payer, a D.0 electronic transaction must be submitted. Required if the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) If the medication is not on the family planning-related drug list, then the prescriber will need to complete a prior authorization to confirm that the drug was prescribed in relation to a family planning visit. WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Submit a dispensing fee as you would for the network contract Submit an Incentive Amount in accordance with Professional Required when Dispensing Status (343-HD) on submission is "P" (Partial Fill) or "C" (Completion of Partial Fill) and Flat Sales Tax Amount Paid (558-AW) is greater than zero (0). WebAWP Reimbursement Basis - Complete the following tables using the drug reimbursement that your organization is willing to guarantee on a dollar-for-dollar basis for each year of the contract. 513-FD: REMAINING DEDUCTIBLE AMOUNT RW: Provided for informational Required when necessary to identify the Plan's portion of the Sales Tax. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL
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