KMAP BULLETIN: Pharmacy Coordination of Benefits Contractual Write-Off - New NCPDP Payer Sheets
Date: 01/19/23
KMAP GENERAL PHARMACY 22315 (PDF)
In April 2022, General Bulletin 22048 notified providers of reimbursement changes related to KMAP as a secondary payer:
Effective for claims processed on and after April 4, 2022, the Kansas Medical Assistance Program (KMAP) will only pay for KMAP-covered services that are also covered by other insurance if the Medicaid payment rate is higher than the amount paid by the primary insurance, and, within this limit, will only pay to the extent necessary to pay the member’s cost-sharing liability.
These changes impact retail pharmacy claims processed as of April 4, 2022. To provide further clarity for pharmacy providers and associated software vendors, note the following updates and changes specific to fee-for-service (FFS) retail pharmacy claims:
- New Payer Sheets for standard FFS claims processing and use of Full Disclosure for RX BIN 610517.
- New Payer Sheets for FFS claims processing and billing of Medicare Part D Copay Assistance/Patient Responsibility for RX BIN 610517 and PCN MEDD.
- Updates to the Pharmacy Provider manual and the General TPL Payments manual.
Medicaid/AIDS Drug Assistance Program (ADAP) are the payers of last resort. Submit the claim to the member’s other insurer(s) before submitting to FFS. The Other Coverage Code (308-C8) value in the Claim Segment of the National Council for Prescription Drug Programs (NCPDP) transaction is a key driver for claims processing and pricing when Medicaid/ADAP are downstream payers. Significant COB Segment fields required are included based on the OCC value listed in the following table. Review the specific Payer Sheets for full direction.
| Other Coverage Code (308-C8) | Significant COB Segment Fields Required | Payer Sheets |
|---|---|---|
2 Other Coverage Exists–Payment Collected | OPAP* Count (341-HB) OPAP Qualifier (342-HC) OPAP (431-DV) OPPR* Count (353-NR) OPPR Qualifier (351-NP) OPPR Amount (352-NQ) | Standard Processing – COB Scenario 3 (Excluding Medicare Part D) |
3 Other Coverage Billed–Claim Not Covered | Other Payer Reject Count (471-5E) Other Payer Reject Code (472-6E) | Both |
4 Other Coverage Exits–Payment Not Collected | OPAP* Count (341-HB) OPAP Qualifier (342-HC) OPAP (431-DV) OPPR* Count (353-NR) OPPR Qualifier (351-NP) OPPR Amount (352-NQ) | Standard Processing – COB Scenario 3 (Excluding Medicare Part D) |
8 Claim Is Billing For Patient Financial Responsibility Only | OPPR Count (353-NR) OPPR Qualifier (351-NP) OPPR Amount (352-NQ) | Medicare Part D Copay Assistance/Patient Responsibility – COB Scenario 2 |
Review the following NCPDP Version D.0 and 1.2 Transactions Payer Sheets available in the HIPAA Companion Guides located on the KMAP website:
- Standard Processing – COB Scenario 3 (Excluding Medicare Part D)
- Medicare Part D Copay Assistance/Patient Responsibility – COB Scenario 2