CVS Caremark Payer Sheet

CVS Caremark Payer Sheet

Commercial Other Payer Amount Paid

Table of Contents ?

HIGHLIGHTS ? Updates, Changes & Reminders ...................................................... 3 PART 1: GENERAL INFORMATION ........................................................................... 4 ? Pharmacy Help Desk Information ....................................................................... 4 PART 2: BILLING TRANSACTION / SEGMENTS AND FIELDS............................ 5 PART 3: REVERSAL TRANSACTION ...................................................................... 12 PART 4: PAID (OR DUPLICATE OF PAID) RESPONSE ...................................... 13 PART 5: REJECT RESPONSE .................................................................................. 18 APPENDIX A: BIN / PCN COMBINATIONS............................................................. 22 ? BIN and PCN Values .......................................................................................... 22 APPENDIX B: COORDINATION OF BENEFITS (COB) ........................................ 23 ? Commercial OPAP Billing (Other Payer Amount Paid) ................................. 23 APPENDIX C: COMPOUND BILLING....................................................................... 24 ? Route of Administration Transition ................................................................... 24

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HIGHLIGHTS ? Updates, Changes & Reminders

This payer sheet refers to Commercial Other Payer Amount Paid (OPAP) Billing. Refer to under the Health Professional Services link for additional payer sheets regarding the following:

Commercial Primary Commercial Other Payer Patient Responsibility (OPPR) Medicare Part D Primary Billing and Medicare as Supplemental Payer Billing Medicare Part D Other Payer Patient Responsibility (OPPR) Medicare Part D Other Payer Amount Paid (OPAP) ADAP/SPAP Medicare Part D Other Payer Patient Responsibility (OPPR) Medicaid Primary Billing & Medicaid as Secondary Payer Billing Other Payer Amount Paid (OPAP) Medicaid Primary Billing & Medicaid as Secondary Payer Billing Other Payer Patient Responsibility (OPPR)

To prevent point of service disruption, the RxGroup must be submitted on all claims and reversals.

The following is a summary of our new requirements. The items highlighted in the payer sheet illustrate the updated processing rules.

Updated ECL Version to Oct 2019 Added Bin 020123 and Helpdesk number Added PCN IRXCOMAP Added field 46?-ET Quantity Prescribed (Effective 09/21/2020) Moved BIN 610502 to Payer Sheet (no changes were made to current setups)

o Added PCNs 00670000 o Added Helpdesk number 1-8??-238-6279 Added Bin 020388 and Helpdesk number

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PART 1: GENERAL INFORMATION

Payer/Processor Name: CVS Caremark? Plan Name/Group Name: All Effective as of: January 2?21 Payer Sheet Version: 2.0.2 NCPDP Version/Release #: D.? NCPDP ECL Version: Oct 2?19 NCPDP Emergency ECL Version: Jan 2?19

Pharmacy Help Desk Information

Inquiries can be directed to the Interactive Voice Response (IVR) system or the Pharmacy Help Desk. (24 hours a day)

The Pharmacy Help Desk numbers are provided below:

CVS Caremark? System

Legacy ADV Legacy PCS

FEP Legacy CRK Legacy PHC

Legacy AmeRx

Aetna

IngenioRX

BIN

Help Desk Number

*013089

*013089

610239 *013089

610468, 006144 004245, 610449 610474, 603604 610473, 601475 007093, 012189 013303, 014046 610130, 610477

610502

020099 020115 020123 020388

1-8??-364-6331 1-8??-345-5413 1-8??-364-6331 1-8??-421-2342 1-8??-777-1023

1-866-668-6681

1-8??-238-6279 1-833-296-5037 1-833-296-5037 1-833-296-5038 1-833-296-5038

*Help Desk phone number serving Puerto Rico Providers is available by calling toll-free 1-8??-842-7331.

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PART 2: BILLING TRANSACTION / SEGMENTS AND FIELDS

The following table lists the segments available in a Billing Transaction. Pharmacies are required to submit upper case values on B1/B2 transactions. The table also lists values as defined under

Version D.?. The Transaction Header Segment is mandatory. The segment summaries included

below list the mandatory data fields.

M ? Mandatory as defined by NCPDP R ? Required as defined by the Processor RW ? Situational as defined by Plan

Transaction Header Segment: Mandatory

Field #

NCPDP Field Name

Value

1?1-A1 BIN Number

610415, 004336 610029, 610468

006144, 004245

610449, 610474

603604, 007093

610473, 601475

012189, 013303

014046, 610130

610477, 610239

013089, 020099

020115, 020123

610502, 020388

1?2-A2 Version/Release Number

D?

Req Comment M

M NCPDP vD.?

1?3-A3 Transaction Code 1?4-A4 Processor Control Number

1?9-A9 Transaction Count 2?2-B2 Service Provider ID Qualifier 2?1-B1 Service Provider ID

4?1-D1 Date of Service 11?-AK Software Vendor/Certification ID

B1

1, 2, 3, 4 ?1

M Billing Transaction M Use value as printed on ID card, as

communicated by CVS Caremark? or as stated in Appendix A M M ?1 ? NPI M National Provider ID Number assigned to the dispensing pharmacy M CCYYMMDD M The Software Vendor/Certification ID is the same for all BINs. Obtain your certification ID from your software vendor. Your Software Vendor/Certification ID is 1? bytes and should begin with the letter "D".

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Insurance Segment: Mandatory

Field #

NCPDP Field Name

111-AM Segment Identification

3?2-C2 Cardholder ID 3?1-C1 Group ID

3?3-C3 Person Code

3?6-C6 Patient Relationship Code

Patient Segment: Required

Field #

NCPDP Field Name

111-AM Segment Identification

3?4-C4 3?5-C5 31?-CA 311-CB 322-CM

Date of Birth Patient Gender Code Patient First Name Patient Last Name Patient Street Address

323-CN Patient City Address

324-CO Patient State/Province Address

325-CP Patient Zip/Postal Zone

335-2C Pregnancy Indicator 384-4X Patient Residence

Value ?4

Req Comment M Insurance Segment

M R As printed on the ID card or as

communicated R As printed on the ID card or as

communicated R

Value ?1

Req Comment M Patient Segment

R CCYYMMDD R R R RW Required for some federal programs

or when submitting Tax RW Required for some federal programs

or when submitting Tax RW Required for some federal programs

or when submitting Tax R Required for some federal programs,

when submitting Sales Tax, or Emergency Override code RW Required for some federal programs RW Required when necessary for plan benefit administration

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Claim Segment: Mandatory

Field #

NCPDP Field Name

111-AM Segment Identification

455-EM 4?2-D2 436-E1

Prescription/Service Reference Number Qualifier Prescription/Service Reference Number Product/Service ID Qualifier

4?7-D7 Product/Service ID

442-E7 4?3-D3 4?5-D5 4?6-D6

Quantity Dispensed Fill Number Days Supply Compound Code

4?8-D8 414-DE 415-DF 419-DJ

DAW / Product Selection Code Date Prescription Written Number of Refills Authorized Prescription Origin Code

354-NX Submission Clarification Code Count

42?-DK Submission Clarification Code

46?-ET Quantity Prescribed

3?8-C8 Other Coverage Code

418-DI Level of Service

454-EK Scheduled Prescription ID Number

461-EU Prior Authorization Type Code

462-EV

995-E2 996-G1 147-U7

Prior Authorization Number Submitted Route of Administration Compound Type Pharmacy Service Type

Value ?7 1 ?3

1 or 2

Max of 3

Req Comment M Claim Segment

M 1 ? Rx Billing

M Rx Number

M If billing for a multi-ingredient prescription, Product/Service ID Qualifier (436-E1) is zero (??)

M If billing for a multi-ingredient prescription, Product/Service ID (4?7D7) is zero (?)

R R R R 1 ? Not a Compound

2 ? Compound R R CCYYMMDD R RW Required when necessary for plan

benefit administration RW Required when Submission Clarification

Code (42?-DK) is used

RW Required for specific overrides or when requested by processor

RW Effective 09/21/2020 Currently Accepted Required when the claim is for a Schedule II drug or when a compound contains a Schedule II drug.

R Required for Coordination of Benefits

?2 ? Other coverage exists, payment collected ?3 ? Other coverage billed, claim not covered ?4 ? Other coverage exists, payment not collected RW Required when requested by processor RW Required when requested by processor RW Required for specific overrides or when requested by processor RW Required for specific overrides or when requested by processor RW Required when Compound Code ? 2 RW Required when Compound Code ? 2 RW Required when necessary for plan benefit administration or when Mail Order / Specialty is submitting sales tax

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Pricing Segment: Mandatory

Field #

NCPDP Field Name

111-AM Segment Identification

4?9-D9 Ingredient Cost Submitted 412-DC Dispensing Fee Submitted 438-E3 Incentive Amount Submitted

481-HA Flat Sales Tax Amount Submitted

482-GE Percentage Sales Tax Amount Submitted

483-HE Percentage Sales Tax Rate Submitted

484-JE Percentage Sales Tax Basis Submitted

426-DQ Usual and Customary Charge 43?-DU Gross Amount Due 423-DN Basis Of Cost Determination

Value 11

Req Comment M Pricing Segment

R R RW Required when requested by

processor RW Required when provider is claiming

sales tax RW Required when provider is claiming

sales tax

Required when submitting Percentage Sales Tax Rate Submitted (483-HE) and Percentage Sales Tax Basis Submitted (484-JE) RW Required when provider is claiming sales tax

Required when submitting Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Basis Submitted (484-JE) RW Required when provider is claiming sales tax

Required when submitting Percentage Sales Tax Amount Submitted (482-GE) and Percentage Sales Tax Rate Submitted (483-HE) R R R

Pharmacy Provider Segment: Situational

Required when needed by plan for Workers Compensation reporting

Field #

NCPDP Field Name

Value

Req Comment

111-AM Segment Identification

?2

M Pharmacy Provider Segment

465-EY Provider ID Qualifier 444-E9 Provider ID

?2

R ?2 ? State License Number

R Pharmacist State License Number

(must be the number of the

pharmacist dispensing the

medication)

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