South Carolina Pharmacy Services

What is a qualifier?

A qualifier identifies the code set being used in the subsequent field. For instance, the Service Provider ID Qualifier of "07" indicates that the number included in the next field, Service Provider ID, will be an NCPDP/NABP number. If the Service Provider ID Qualifier was submitted as an "11", this would indicate that the subsequent field would contain a Federal Tax ID.

What are the appropriate qualifiers for SC Medicaid?

Service Provider ID Qualifier	[202-B2]	- 07	(NCPDP/NABP Provider ID)
Product Service ID Qualifier	[436-E1]	- 03	(NDC)
Prescriber ID Qualifier	[466-EZ]	- 13	(State Issued ID)
Other Payer ID Qualifier	[339-6C]	- 99	(Other, State assigned carrier code)

Are these qualifiers able to be viewed in my system?

These qualifiers are programmed by your software vendor; it is possible that you may be unable to view them on your screen or to modify them.

What do I do when I receive NCPDP Error (88) - DUR?

Call the First Health Services Technical Call Center for assistance if the claim is rejecting for "Early Refill" or use the appropriate DUR Conflict, Intervention and Outcome codes if the claim is rejecting for a "Therapeutic Duplication" or "Drug-to-Drug Interaction". If the claim is rejecting for an "Early Refill" DUR edit, the Technical Call Center (866/254.1669) requires an explanation for the early refill. If certain criteria are met, a prior authorization is granted and the claim may be resubmitted for payment.

NOTE: Instructions on provider level overrides for DUR edits may be found on pages 45 � 47 in the First Health Services Pharmacy Provider Manual.

What do I do when I receive NCPDP Error (E8) - Other Payer Date?

There are several possible TPL code combinations that will result in this rejection. The most common reasons for denials are when the provider submits a Primary Denial Date when the patient does not have other coverage or when the provider does not submit the date when the patient does have other coverage. The provider needs to either enter the Other Payer Date (also referred to as the Primary Denial Date) which equals the date that the primary carrier denied or paid the claim, or remove the date depending on the patient�s TPL coverage.

If the provider enters the prescriber ID in the PRIOR AUTHORIZATION NUMBER field, the claim will also deny for this error. In that case, the provider will need to remove the Prescriber ID from the PRIOR AUTHORIZATION NUMBER field. In some cases a �5� is required in the PRIOR AUTHORIZATION TYPE CODE field if the provider is attempting to override the monthly prescription limitation.

NOTE: Instructions on Coordination of Benefits (COB) claims processing may be found on pages 23 � 29 in the First Health Services Pharmacy Provider Manual.

What do I do when I receive NCPDP Error (41) - Submit Bill to Other Processor or Primary Payer?

This error is sent to alert the Provider that it is necessary to bill the Primary Payer first before billing Medicaid. The provider should verify the Other Coverage Code, TPL Amount, Primary Payer Denial Date, and TPL Carrier Code (entered in the OTHER PAYER ID field #340-7C). Depending on the patient�s TPL coverage, the provider needs to enter the appropriate TPL codes that will allow the claim to pay according to the given situation.

NOTE: Instructions on Coordination of Benefits (COB) claims processing may be found on pages 23 � 29 in the First Health Services Pharmacy Provider Manual.

What do I do when I receive NCPDP (13) - M/I Other Coverage Code?

The provider should verify the OTHER COVERAGE CODE field. There are several situations depending on the patient�s TPL coverage, which drives the OTHER COVERAGE CODE field. The field should always be used when other coverage is being filed.

NOTE: Instructions on Coordination of Benefits (COB) claims processing may be found on pages 23 � 29 in the First Health Services Pharmacy Provider Manual.

What do I do when I receive NCPDP (DV) - Other Payer Amount?

The provider should verify the OTHER PAYER AMOUNT field. Providers frequently forget to populate this field. The only time this field is used is when TPL billing is required and the payment was collected from the primary payer. When using OTHER OCCURRENCE CODE = "2" to declare a primary payment, the insurance payment amount must always be put into the OTHER PAYER AMOUNT field.

NOTE: Instructions on Coordination of Benefits (COB) claims processing may be found on pages 23 � 29 in the First Health Services Pharmacy Provider Manual.

What do I do when I receive NCPDP (7C) - M/I Other Payer ID?

The provider should verify the OTHER PAYER ID field. If the provider is submitting a TPL claim and has entered all fields except the carrier code in OTHER PAYER ID field, the claim will deny. The Technical Call Center will assist the provider by furnishing the appropriate 5-digit carrier code that needs to be entered. First Health Services also sends back an additional message that may assist the pharmacist in troubleshooting the denial.

NOTE: Instructions on Coordination of Benefits (COB) claims processing may be found on pages 23 � 29 in the First Health Services Pharmacy Provider Manual.

What do I do when I receive NCPDP (69) - Filled After Coverage Terminated?

Call the Technical Call Center to verify the eligibility dates for the patient in question. NOTE: This error cannot be overridden. Only providers wishing to inform patients of coverage dates should call in regard to this error.

Why am I getting this payment amount?

The Technical Call Center often responds to calls where the provider has entered an amount in the PATIENT PAID AMOUNT field, thus adversely affecting payment. The Technical Call Center instructs the provider to remove the amount in the PATIENT PAID AMOUNT field and resubmit the claim for proper payment.

How do I bill for home-administered injectable products?

The provider should verify that the medication is being administered in the home and if so, enter a "1" in the PRIOR AUTHORIZATION TYPE CODE field and a "01" in the CUSTOMER LOCATION field.

NOTE: Instructions on claims submission for Home-Administered Injectables may be found on page 19 in the First Health Services Pharmacy Provider Manual.

Why must patient-specific DUR messages be overridden month after month?

There are two ProDUR denial messages which may be overridden by the provider. The two messages are: Therapeutic Duplication and Drug-to-Drug Interaction. Both of these edits require that the provider review the patient�s drug utilization and confirm appropriate drug therapy. Since information and warnings concerning drugs change frequently, it was determined that these two edits should be evaluated each time they occur in order to ensure appropriate drug therapy.

Whom should I call if I receive NCPDP (75) - Prior Authorization Required?

The majority of rejections for NCPDP edit 75 require contact with First Health Services' Clinical Call Center staff. All rejections requiring clinical intervention will return the message "PA Required MD Call 866-247-1181". It is not necessary to contact First Health Services staff for the following drugs:

• Lactulose
• Tretinoin (Retin A®, Avita®, and Differin®) for adult patients (greater than age 21)
• Home-administered injectable products (not that injectable drugs used to treat erectile dysfunction require clinical prior authorization)
• Amphetamines for adult patients (greater than age 21)

When a rejection is received for any of the items listed above, the provider has the capability to override the rejection by using the PRIOR AUTHORIZATION TYPE CODE field.

NOTE: Instructions for Provider Level Overrides may be found on page 19 in the First Health Services Pharmacy Provider Manual.

What should I do if I receive NCPDP (25) - M/I Prescriber ID?

Pharmacy Services providers are instructed to submit all prescriber identification numbers using a total of 10 bytes. Providers are reminded that Prescriber Identification numbers that are on file may be found under the �Listings� section on this website. If the correct 10-byte state license number cannot be determined by following these instructions then the Technical Call Center may be contacted for assistance (1-866-254-1669).

NOTE: Instructions regarding how to properly format Prescriber Identification Numbers may be found in the Medicaid bulletin dated October 31, 2002.

What if I do not understand what a particular error code means?

A list of Point of Sale Reject Codes and Messages is located in the First Health Services Pharmacy Provider Manual on pages 35 - 45.

How is the state MAC price derived?

First Health Services� state Maximum Allowable Cost (MAC) procedures are as follows: First Health Services reviews the most current First DataBank drug file and applies the proprietary First Health Services algorithm to determine the current month's state MAC pricing list. The algorithm addresses non-rebated, rebated, and obsolete drugs, therapeutic equivalency ratings, single-source and multiple-source products and costs. A proposed specific drug product (GSN) state MAC pricing list is produced, and the list is then subjected to clinical and business review.