Prescribed Drugs Provider Manual - Iowa Department of Human ...

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage101DateAugust 1, 2013FIELD NAME/DESCRIPTIONINSTRUCTIONS44 – PA TYPE CONDITIONAL. Enter code “2” if a number wasentered in the “PRIOR AUTH # SUBMITTED” box.Otherwise, leave blank.45 – OTHER COVERAGE CODE CONDITIONAL. To determine whether the memberhas drug coverage under other insurance, checkthe member’s eligibility using the EligibilityVerification System (ELVS) or the IME web portal.♦♦♦♦If a member has Iowa Medicaid pharmacyinsurance only and no other primary insurance,leave this field blank or enter a zero.Enter code “1” if the member states there is noother insurance but the claim has already beenrejected with a reject code of 41 “Submit toPrimary Payer.” Iowa Medicaid’s eligibility fileconflicts with the primary third-party insurancecompany’s information.Enter code “3” if other coverage does exist andthe drug is not covered under the primaryinsurance plan. NOTE: Also allowed for PartD excluded drugs.Enter code “8” when billing is for patientfinancial responsibility.46 – DELAY REASON NOT USED.47 – LEVEL OF SERVICE NOT USED.48 – PLACE OF SERVICE OPTIONAL.CLINICAL49 – DIAGNOSIS CODE NOT USED.Only the indicator “06 = Patient Pay Amount”will be accepted as an other payer-patientresponsibility amount qualifier.50 – DIAGNOSIS CODEQUALIFIERNOT USED.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage102DateAugust 1, 2013FIELD NAME/DESCRIPTIONINSTRUCTIONSDUR51 – DUR/PPS CODE REASON Leave blank.52 – DUR/PPS CODE SERVICE Leave blank.53 – DUR/PPS CODE RESULT Leave blank.54 – LEVEL OF EFFORT Leave blank.55 – PROCEDURE MODIFIER Leave blank.COB OTHER PAMENTSCOB1 – PRIMARY56 – OTHER PAYER ID REQUIRED FOR COB. Primary payer.57 – OTHER PAYER IDQUALIFIERREQUIRED FOR COB. Primary payer.58 – OTHER PAYER DATE REQUIRED FOR COB. Primary payer.If the patient has other insurance coverage, enterthe date the claim was paid or rejected by theother insurer.59 – OTHER PAYER REJECTCODESCONDITIONAL. If the patient has other insurancecoverage but the claim was rejected, enter therejection codes assigned by the other insurer (ifknown).COB1 – SECONDARY60 – OTHER PAYER ID REQUIRED FOR COB. Payer ID of primary payer.61 – OTHER PAYER IDQUALIFIERREQUIRED FOR COB.62 – OTHER PAYER DATE REQUIRED FOR COB.If the patient has other insurance coverage, enterthe date the claim was paid or rejected by theother insurer.63 – OTHER PAYER REJECTCODESCONDITIONAL. If the patient has other insurancecoverage but the claim was rejected, enter therejection codes assigned by the other insurer (ifknown).
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