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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage103DateAugust 1, 2013FIELD NAME/DESCRIPTIONINSTRUCTIONSCOMPOUND64 – DOSAGE FORMDESCRIPTION CODE65 – DISPENSING UNIT FORMINDICATOR66 – ROUTE OFADMINISTRATION67 – INGREDIENT COMPONENTCOUNTMANDATORY.MANDATORY.OPTIONAL.MANDATORY.68 – PRODUCT NAME REQUIRED. Submit for each compound component.69 – PRODUCT ID REQUIRED. Submit for each compound component.70 – PRODUCT ID QUALIFIER REQUIRED. Submit for each compound component.71 – INGREDIENT QTY REQUIRED. Submit for each compound component.72 – INGREDIENT DRUG COST OPTIONAL. Submit for each compound component.73 – BASIS OF COST OPTIONAL. Submit for each compound component.PRICING74 – USUAL & CUSTOMARYCHARGE75 – BASIS OF COSTDETERMINATION76 – INGREDIENT COSTSUBMITTEDREQUIRED. Enter the usual and customary charge.CONDITIONAL. Enter code “09” to indicate unit dosedrug. Otherwise, leave blank.REQUIRED. Enter the pharmacy’s submittedproduct component cost of the dispensedprescription. Amount also included in the grossamount due.340B pricing submitted in this field whenapplicable.77 – DISPENSING FEESUBMITTEDREQUIRED. Enter the pharmacy’s usual andcustomary dispensing fee. Enter zeros if nodispensing fee is charged for the prescription.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage104DateAugust 1, 2013FIELD NAME/DESCRIPTION78 – PROFESSIONAL SERVICEFEE SUBMITTED79 – INCENTIVE AMOUNTSUBMITTED80 – OTHER AMOUNTSUBMITTEDINSTRUCTIONSREQUIRED. Enter the pharmacy’s usual andcustomary dispensing fee. Enter zeros if nodispensing fee is charged for the prescription.Leave blank.Leave blank.81 – SALES TAX SUBMITTED NOT USED.82 – GROSS AMOUNT DUE REQUIRED. Enter the total charge for this item.The total claim charge must be equal to the sum ofthe submitted ingredient cost submitted and thesubmitted dispensing fee.83 – PATIENT PAID AMOUNT Leave blank.84 – OTHER PAYER AMOUNTPAID #185 – OTHER PAYER AMOUNTPAID #286 – OTHER PAYER-PATIENTRESPONSIBILITY AMOUNT #187 – OTHER PAYER-PATIENTRESPONSIBILITY AMOUNT #2NOT USED.NOT USED.REQUIRED FOR IA COB CLAIMS.REQUIRED FOR IA COB CLAIMS.88 – NET AMOUNT DUE REQUIRED. Enter the total price less the deductibleamount. NOTE: If resubmitting a claim that is over12 months old, the word “resubmit” must clearlyappear on the claim to avoid denials for timelyfiling. This procedure can be used only if theoriginal submission was within the last 12 months.
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