NCPDP vD.0 Implementation, Frequently Asked Questions
Will I be able to test with MO HealthNet prior to D.0 implementation?
Wipro Infocrossing, MO HealthNet's Fiscal Agent is currently accepting test claims. Providers are encouraged to test with Wipro Infocrossing immediately. The Wipro Infocrossing Help Desk may be reached at 573/635-3559 or via email at the HIPAA Support address email@example.com.
What is MO HealthNet’s testing requirements?
To test with MO HealthNet, the appropriate access account application, and Trading Partner Agreement forms, available at
http://dss.mo.gov/mhd/providers/ must be complete and on file with Wipro.
Following completion of these forms, the Trading Partner's User ID and password (where applicable) is given to them at this time. The Wipro Help Desk then notifies the biller that they are approved to send test transactions for those transactions they indicated on the Trading Partner Agreement form.
The biller should contact the Wipro Help Desk at (573) 635-3559 or by email at firstname.lastname@example.org for information regarding which switching companies have an existing connection with MO HealthNet.
When will D.0 testing occur?
Wipro Infocrossing is currently accepting test claims. We encourage providers to submit test claims as soon as possible.
Does MO HealthNet have a payer sheet?
MO HealthNet has a companion guide available for your convenience at the following link:
The NCPDP Transaction Standard Companion Guide explains the procedures necessary for trading partners to successfully exchange transactions electronically with MO HealthNet in standard HIPAA compliant forms. These transactions include the following:
- NCPDP Telecommunication Standard Version D.0
- NCPDP Batch Standard Version 1.2
- NCPDP External Code List (ECL); March 2010
- NCPDP Emergency Telecommunication External Code List Value (ECL) Addendum; July 2011
This Companion Guide is intended to convey information that is within the framework and structure of the NCPDP Implementation Guides and not to contradict or exceed them.
Will MO HealthNet allow a period of enforcement discression for compliance with new HIPPA transaction standards?
Yes, pursuant to guidance issued by CMS in November, MO HealthNet will allow a discretionary period of January 1, 2012 through March 31, 2012 for compliance with the ASC X12 Version 5010 and NCPDP Telecom D.0 transaction standards. MO HealthNet will not initiate enforcement action against or withhold payment from providers who are noncompliant on January 1, 2012. However, failure to convert on January 1, 2012 will increase the risk of issues with claims processing and disruption in payment. MO HealthNet will enforce compliance when the discretionary period authorized by CMS ends on April 1, 2012.
When will eMOMED, Mo HealthNets web portal, implement vD.0?
The eMOMED conversion occurred December 18, 2011. There will be no discretionary period for eMOMED. vD.0 rules will apply to all claims processed on eMOMED after the conversion.
What methodology will MO HealthNet use to process Third Party Liability (TPL) claims for Fee-For-Service (FFS) and MoRx programs?
With the implementation of NCPDP vD.0, MO HealthNet will use the Government Coordination of Benefits (COB) methodology to process Third Part Liability (TPL) claims for both Fee-For-Service (FFS) and MoRx programs.
What Other Coverage Codes will be accepted by MO HealthNet with the NCPDP vD.0?
For TPL claims Other Coverage Codes (OCC) 02, 03, and 04 will be allowed. For claims billed to MO HealthNet as primary payer OCC 00 or 01 will be allowed.
Other Coverage Codes
|00||Not Specified by patient|
|01||No other coverage|
|02||Other Coverage exists-payment collected|
|03||Other Coverage billed-claim not covered|
|04||Other Coverage exists-payment not collected|
MO HealthNet will no longer accept 07 or 08 in the Other Coverage Code field.
What fields are required for Government COB for Fee-For-Service?
The NCPDP v5.1 term Co-Pay/Co-Insurance has been changed to Patient Responsibility Amount in NCPDP vD.0. The Government COB method requires providers to submit the Other Payer Amount Paid [431-DV] AND the Other Payer-Patient Responsibility Amount [352-NQ]. Using this method allows MO HealthNet to reimburse claims based on the lower of Other Payer Paid Amount or Other Payer-Patient Responsibility amount calculations.
What should I do if the primary payer does not send Patient Responsibility Amount?
When the primary payer does not send Patient Responsibility Amount, providers are required to submit a zero dollar amount ($0.00).
What qualifiers will MO HealthNet accept for Patient Responsibility Amount?
For FFS TPL claims, when payment is based on the Other Payer-Patient Responsibility Amount, only the Patient Pay Amount qualifier [351-NP] value of 06 will be accepted by MO HealthNet.
'06' – Patient Pay Amount (505-f5) as reported by previous payer. Used to indicate the provider is submitting the amount reported by a prior payer as the patient’s responsibility.
What qualifiers will MO HealthNet accept for Other Payer Amount Paid?
MO HealthNet will accept a ‘07’ only.
'07' – Drug Benefit – An indicator which signifies when the dollar amount paid by the other payer has been paid as part of the drug benefit plan.
What if the primary payer sends Other Payer-Patient Responsibility only?
The provider must submit the Other Payer Patient Responsibility amount, with a 04 in the Other Coverage Code (OCC) field.
If a primary payer denies a claim, how do I process the claim to MO HealthNet?
NCPDP vD.0 requires a 03 in the Other Coverage Code field when the primary payer denies the claim. Providers must also submit a reject code that is considered an accepted value by MO HealthNet.
Will MO HealthNet allow providers to submit a 02 in the Eligibility Clarification Code to bypass TPL edits in vD.0?
No. MO HealthNet will no longer allow providers to use a 02 to bypass TPL edits in vD.0.
How many characters are accepted by MO HealthNet for a Prescription number in vD.0?
Prescription number has been expanded from 7 to 12 characters. Providers are not required to submit 12 characters; however MO HealthNet will accept the number of characters up to 12 digits.
How do providers get the Long Term Care dispensing fee?
In NCPDP vD.0 the qualifications for determining the controlled dose long-term care prescription fee differential will be based on Patient Residence [384-4X], values 02 or 03 and Special Packaging Indicator [429-DT], values 03 or 04.
|02||Skilled Nursing Facility|
Special Packaging Indicator
|03||Pharmacy Unit Dose|
During the discretionary period will my outbound 835 Remittance Advice be v4010 or v5010?
Beginning January 1, 2012 MO HealthNet will send all outbound 835 remittance advice transactions in the v5010 format unless the provider has contacted Wipro Infocrossing via email at email@example.com to request temporary conversion back to the v4010 format.
What fields are required for Government COB for MoRx?
The Benefit Stage Amount is the amount of the claim allocated to the Medicare (TrOOP) stage identified by the benefit stage qualifier, and allows MO HealthNet to identify the stage of benefit for the participant. Benefit Stage Amount [394-MW] repetitions are required when a prior payer is a Medicare Drug Insurance plan.
What qualifiers will MoRx accept for Patient Responsibility Amount?
This field is used to indicate the provider is submitting the amount reported by a prior payer as the patient’s responsibility. For MoRx claims, values 01, 02, 03, 04, 05, 07, 08, 09, 10, 11, 12, or 13 will be accepted — 06 from any prior payer will deny.
Will MO HealthNet staff be available on January 1, 2012 to answer claims processing questions?
No, however, MO HealthNet staff will be available on January 2, 2012 to answer provider questions/concerns from 8:00 to 5:00 at 573-751-6963.