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Elizabeth M. Whitehorn, Director

Provider Notice issued 06/06/06

Medicare Part D Copayment Billing for SLF and CILA Residents REVISED INSTRUCTIONS

To:​ ​Pharmacies
​Date: ​June 6, 2006
​Re: ​Medicare Part D Copayment Billing for SLF and CILA Residents REVISED INSTRUCTIONS

This notice provides updated instructions on billing copay-only claims for residents of SLFs and CILAs who are enrolled in Medicare Part D. The Illinois Department of Healthcare and Family Services (HFS) posted instructions in a May 1, 2006 notice at http://www.hfs.illinois.gov/assets/050106copay.pdf

The change to the previous instructions relates to the Usual and Customary Charge Field (426-DQ). The value in the Usual and Customary Charge Field should not be $0. It should be the amount charged cash customers for the prescription exclusive of sales tax or other amount claimed. All other instructions remain the same. Complete billing instructions are below.

 

NCPDP 5.1 Claim Segment field and valid value:

Other Coverage Code value (308-C8)

 

Value = 08 (Claim is billing for co-pay)

 

NCPDP 5.1 Pricing Segment fields and valid values:

Other Amount Claims Submitted Count (478-H7) Value = 1
Other Amount Claims Submitted Qualifier (479-H8) Value = 99 (Other)
Other Amount Claimed Submitted (480-H9) Value = Copay amt. ($1 - $5)
Gross Amount Due (430-DU) Value = Copay amt. ($1 - $5)
Usual and Customary Charge (426-DQ)

Value = Amount charged cash customers for the prescription exclusive of sales tax or other amount claimed

 

Copay-only claims must not contain a NCPDP 5.1 COB/Other Payments Segment.

Questions regarding billing of copay-only claims may be directed to the HFS Pharmacy Billing Consultants at 217-782-5565.