Last Updated: August 2Ø12. August 2Ø12. National Council for Prescription Drug Programs 924Ø East Raintree Drive Scottsdale, AZ 8526Ø

(1)

Income Subsidy (LICS/LIS) Adjustments Reporting on the

ASC X12/ØØ5Ø1ØX221A1 Health Care Claim Payment/Advice

(835)

Last Updated: August 2Ø12

August 2Ø12

National Council for Prescription Drug Programs

924Ø East Raintree Drive

Scottsdale, AZ 8526Ø

Phone: (48Ø) 477-1ØØØ

Fax: (48Ø)

767-1Ø42

E-mail:

ncpdp@ncpdp.org

http:

www.ncpdp.org

(2)

NCPDP Medicare Part D Low Income Cost Sharing/Low Income Subsidy (LIS/LIS) Adjustments Reporting on the ASC X12/ØØ5Ø1ØX221A1 Health Care Claim Payment/Advice (835)

Page 2 of 16 Date: August 2012

NCPDP Medicare Part D Low Income Cost Sharing/Low Income Subsidy

(LICS/LIS) Adjustments Reporting on the ASC X12/ØØ5Ø1ØX221A1 Health Care

Claim Payment/Advice (835)

NCPDP recognizes the confidentiality of certain information exchanged electronically through the use of its

standards. Users should be familiar with the federal, state, and local laws, regulations and codes requiring

confidentiality of this information and should utilize the standards accordingly.

NOTICE:

In addition, this NCPDP Standard contains certain data fields and elements that may be completed by

users with the proprietary information of third parties. The use and distribution of third parties' proprietary information

without such third parties' consent, or the execution of a license or other agreement with such third party, could

subject the user to numerous legal claims.

All users are encouraged to contact such third parties to determine

whether such information is proprietary and if necessary, to consult with legal counsel to

make

arrangements for the use and distribution of such proprietary information

.

Published by:

Publication History:

Version 1.Ø xx 2Ø12

Data Interchange Standards Association on behalf of ASC X12. Format © 2Ø11 Washington Publishing Company. Exclusively published by the Washington Publishing Company.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the copyright owner.

All rights reserved.

No part of this manual may be reproduced in any form

or by any means without permission in writing from:

924Ø East Raintree Drive

Scottsdale, AZ 8526Ø

(48Ø) 477-1ØØØ

ncpdp@ncpdp.org

(3)

X12/ØØ5Ø1ØX221A1 Health Care Claim Payment/Advice (835)

BUSINESS CASE 4: INCREASE IN THE BENEFICIARIES PATIENT RESPONSIBILITY (COPAY) 13

4.

REVISION HISTORY ... 16

(4)

1. DISCLAIMER

This Reference Guide must be used in conjunction with the ASC

X12/ØØ5Ø1ØX221A1 Health Care Claim

Payment/Advice (835).

This document does not supersede ØØ5Ø1ØX221A1. There may be other fields that must be

populated that are not noted in this reference guide. This guidance only addresses claims submitted through NCPDP

transactions or paper claim forms.

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X12/ØØ5Ø1ØX221A1 Health Care Claim Payment/Advice (835)

2.

PURPOSE OF THIS DOCUMENT

Payers may use this guidance to convey a consistent solution for identifying retro-active Low Income Subsidy (LIS)

adjustment of pharmacy claims using the ØØ5Ø1ØX221A1 to their long term care (LTC) business partners. The

document should not be used as a standard form to be filled in by payers to provide information that is important to

pharmacy providers, pharmacy reconciliation vendors, and other implementation units.

(6)

3. ØØ5Ø1ØX221A1 LOW INCOME SUBSIDY (LIS) ADJUSTMENT

EXAMPLES

The examples include the following four possible business cases:

•

Business Case 1: Series of Copay Changes

•

Business Case 2: Series of Adjustment Types

•

Business Case 3: Multiple Adjustments in Once Cycle

•

Business Case 4: Increase in the Beneficiaries Patient Responsibility

Legend:

ØØ5Ø1ØX221A1 Field

Values/Comments

CLPØ2 – Claim Status Code1

1 = Processed as Primary. 22 = Reversal of previous payment.

Note: The correction should be reflective of the CLPØ2 in original payment. Therefore if a 1, 2, or 3 is sent on the original payment, the reversal should contain the same CLPØ2 value.

CLPØ6 – Claim Filing Indicator Code2 13 = Point of service

ZZ = Mutually Defined

CASØ1 – Claim Adjustment Group Code3 CO = Contractual obligation

PR = Patient Responsibility CASØ2 – Claim Adjustment Reason Code used with Group Code

PR

3 = Copayment amount

241 - Low Income Subsidy (LIS) Copayment Amount CASØ2 – Claim Adjustment Reason Code used with Group Code

CO

9Ø = Ingredient cost adjustment

1ØØ = Payment made to patient/insured/responsible party/employer

Business Rule: The value of "ZZ" will appear in CLPØ6 if any adjustment to the claim was for LIS. If there was no

adjustment for LIS, then the CLPØ6 would contain the value "13" and the CAS would be calculated based on the

original submission of the claim. In this example CASØ1 would be PR and CASØ2 would be 3 for Copayment Amount.

3.1 B

USINESS

C

ASE

1:

S

ERIES OF

C

OPAY

C

HANGES

3.1.1 B

USINESS

C

ASE

1.Ø

LTC Pharmacy has attestation with Plan for limited reimbursement for LIS-eligible enrollees residing in Skilled Nursing

Facilities.

On date of service patient had no LIS (Low Income Subsidy). Previously, the payer remitted a retro LIS adjustment of

$23.7Ø to the patient to reflect LIS Category 1, copay of $6.3Ø versus the original copay of $3Ø.ØØ.

The claim example

4

below illustrates transaction sets where a payer had made a full payment on a claim in a previous

cycle (Cycle1). The payer sends a reversal and correction in a subsequent cycle (Cycle 2) to adjust the Patient

Responsibility Amount and Claim Payment Amount to reflect a retro LIS adjustment for the patient to LIS Category 2,

copay of $3.3Ø.

1

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "Claim Status Code” Health Care Claim

Payment/Advice (835) 005010X221A1 page 124. Washington Publishing Company, Apr. 2006. <http://www.wpc-edi.com>.

2

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "Claim Filing Indicator Code” Health Care Claim

Payment/Advice (835) 005010X221A1 pages 126-127. Washington Publishing Company, Apr. 2006.

<http://www.wpc-edi.com>.

3

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "Claim Adjustment Group Code” Health Care

Claim Payment/Advice (835) 005010X221A1 page 198. Washington Publishing Company, Apr. 2006.

<http://www.wpc-edi.com>.

4

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "10.1.2 Data Use by Business Use” Health Care

Claim Payment/Advice (835) 005010X221A1. Washington Publishing Company, Apr. 2006. <http://www.wpc-edi.com>.

(7)

The Patient Responsibility amount has decreased $26.7Ø from $3Ø.ØØ to $3.3Ø (previous adjustment of $23.7Ø paid

to member and current adjustment of $3.ØØ). The Claim Payment Amount has increased $3.ØØ from 158.87 to

$161.87 resulting in a remittance of $3.ØØ to the LTC Pharmacy.

The total amount paid to the provider reported on the 835 in BPRØ2 for cycle 1 is $1ØØØ.ØØ which includes the

$158.87 for this claim. For cycle 2 since the reversal and correction must be reported on the same 835 the total

amount paid reported to the provider is $1ØØ3.ØØ which includes the reversal of 158.87 and the corrected claim

amount of $161.87. Other claim activity = $1ØØØ.ØØ, Reversal = $158.87, Corrected Claim = $161.87

(1ØØØ.ØØ-158.87+161.87 =1ØØ3.ØØ).

Note: Reversal and Corrections are required to be submitted in the same cycle with the ØØ5Ø1ØX221A1.

Loop Reference Designator

Definition Cycle 1 (Payment) Cycle 2 (Reversal) Cycle 2 (Correction)

Total Actual Provider Payment

Amount BPRØ2: 1ØØØ.ØØ BPRØ2: 1ØØ3.ØØ BPRØ2: 1ØØ3.ØØ

21ØØ Claim Submitter's Identifier CLPØ1: 1234589 CLPØ1: 1234589 CLPØ1: 1234589

Claim Status Code CLPØ2: 1 CLPØ2: 22 CLPØ2: 1

Total Claim Charge Amount CLPØ3: 242.8Ø CLPØ3: -242.8Ø CLPØ3: 242.8Ø

Claim Payment Amount CLPØ4: 158.87 CLPØ4: -158.87 CLPØ4: 161.87

Patient Responsibility Amount CLPØ5: 3Ø.ØØ CLPØ5: CLPØ5: 3.3Ø

Claim Filing Indicator Code CLPØ6: 13 CLPØ6: ZZ CLPØ6: ZZ

Entity Identifier Code NM1Ø1: QC NM1Ø1: QC NM1Ø1: QC

Entity Type NM1Ø2: 1 NM1Ø2: 1 NM1Ø2: 1

Patient Last Name NM1Ø3: Last NM1Ø3: Last NM1Ø3: Last

Patient First Name NM1Ø4: First NM1Ø4: First NM1Ø4: First

Identification Code Qualifier NM1Ø8: MI NM1Ø8: MI NM1Ø8: MI

Patient Identifier NM1Ø9: 987654321 NM1Ø9: 987654321 NM1Ø9: 987654321

211Ø Composite Medical Procedure

Code SVCØ1-1: N4 SVCØ1-1: N4 SVCØ1-1: N4

Procedure Code SVCØ1-2: 123456789Ø1 SVCØ1-2: 123456789Ø1 SVCØ1-2: 123456789Ø1

Line Item Charge Amount SVCØ2: 242.8Ø SVCØ2: -242.8Ø SVCØ2: 242.8Ø

Line Item Provider Payment

Amount SVCØ3: 158.87 SVCØ3: -158.87 SVCØ3: 161.87

Quantity SVCØ5: 3Ø SVCØ5: 3Ø SVCØ5: 3Ø

Date Time Qualifier DTMØ1: 472 DTMØ1: 472 DTMØ1: 472

Service Date DTMØ2: 2Ø111Ø15 DTMØ2: 2Ø111Ø15 DTMØ2: 2ØØ6Ø7Ø1

Claim Adjustment Group Code CASØ1: PR CASØ1: PR CASØ1: PR

Claim Adjustment Reason

Code CASØ2: 3 CASØ2: 3 CASØ2: 241

Adjustment Amount CASØ3: 3Ø.ØØ CASØ3: -3Ø.ØØ CASØ3: 3.3Ø

Claim Adjustment Group Code CASØ1: CO CASØ1: CO CASØ1: CO

Code CASØ2: 9Ø CASØ2: 9Ø CASØ2: 9Ø

Adjustment Amount CASØ3: 53.93 CASØ3: -53.93 CASØ3: 53.93

Code CASØ5: 1ØØ

(8)

3.1.2 B

USINESS

C

ASE

1.1

LTC Pharmacy has attestation with Plan for limited reimbursement for LIS-eligible enrollees residing in Skilled Nursing

Facilities.

Cycle 2 Correction reflects claim with LIS Category 2, copay of $3.3Ø.

The claim example

5

below illustrates transaction sets where a payer made a subsequent correction to a correction

submitted in a previous cycle (Cycle 2). The payer sends a reversal and correction in a subsequent cycle (Cycle 3) to

adjust the Patient Responsibility Amount and Claim Payment Amount to reflect a retro LIS adjustment for the patient to

LIS Category 3 (Institutionalized Status), copay of $Ø.ØØ.

The Patient Responsibility amount has decreased from $3.3Ø to $Ø.ØØ. The Claim Payment Amount has increased

$3.3Ø from 161.87 to $165.17 resulting in a remittance of $3.3Ø to the LTC Pharmacy.

The total amount paid to the provider reported on the 835 in BPRØ2 for cycle 2 is $1ØØ3.ØØ which include the

amount paid reported to the provider is $1ØØ3.3Ø which includes the reversal of $161.87 and the corrected claim

(1ØØØ.ØØ-161.87+165.17 =1ØØ3.3Ø).

Loop Reference Designator

Definition Cycle 2 (Correction) Cycle 3 (Reversal) Cycle 3 (Correction)

Amount BPRØ2: 1ØØ3.ØØ BPRØ2: 1ØØ3.3Ø BPRØ2: 1ØØ3.3Ø

Patient Responsibility Amount CLPØ5: 3.3Ø CLPØ5: CLPØ5:

Claim Filing Indicator Code CLPØ6: ZZ CLPØ6: ZZ CLPØ6: ZZ

Amount SVCØ3: 161.87 SVCØ3: -161.87 SVCØ3: 165.17 Quantity SVCØ5: 3Ø SVCØ5: 3Ø SVCØ5: 3Ø ` DTMØ1: 472 DTMØ1: 472 DTMØ1: 472 Service Date DTMØ2: 2ØØ6Ø7Ø1 DTMØ2: 2Ø111Ø15 DTMØ2: 2ØØ6Ø7Ø1

Claim Adjustment Group Code CASØ1: PR CASØ1: PR CASØ1:

5

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "10.1.2 Data Use by Business Use” Health Care

(9)

Loop Reference Designator

Claim Adjustment Reason Code CASØ2: 241 CASØ2: 241 CASØ2:

Adjustment Amount CASØ3: 3.3Ø CASØ3: -3.3Ø CASØ3:

Claim Adjustment Reason Code CASØ2: 9Ø CASØ2: 9Ø CASØ2: 9Ø

Claim Adjustment Reason Code CASØ5: 1ØØ CASØ5: 1ØØ CASØ5: 1ØØ

Adjustment Amount CASØ6: 23.7Ø CASØ6: -23.7Ø CASØ6: 23.7Ø

3.2 B

USINESS

C

ASE

2:

S

ERIES OF

A

DJUSTMENT

T

YPES

3.2.1 B

USINESS

C

ASE

2.Ø

LTC Pharmacy has attestation with Plan for full reimbursement for LIS-eligible enrollees residing in Skilled Nursing

Facilities.

On date of service patient had no LIS (Low Income Subsidy).

The claim example

6

cycle (Cycle1). The payer sends a reversal and correction in a subsequent cycle (Cycle 2) to adjust the Patient

copay of $3.3Ø.

The Patient Responsibility amount has decreased $26.7Ø from $3Ø.ØØ to $3.3Ø. The Claim Payment Amount has

increased $26.7Ø from 158.87 to $185.57 resulting in a remittance of $26.7Ø to the LTC Pharmacy.

The total amount paid to the provider reported on the 835 in BPRØ2 for cycle 1 is $1ØØØ.ØØ which include the

$158.87 for this claim. For cycle 2 since the reversal and correction must be reported on the same 835 the total

amount paid reported to the provider is $1Ø26.7Ø which includes the reversal of 158.87 and the corrected claim

(1ØØØ.ØØ-158.87+185.57 =1Ø26.7Ø)

Loop Reference Designator

Total Actual Provider

Payment Amount BPRØ2: 1ØØØ.ØØ BPRØ2: 1Ø26.7Ø BPRØ2: 1Ø26.7Ø

Patient Responsibility Amount CLPØ5: 3Ø.ØØ CLPØ5: CLPØ5: 3.3Ø

Claim Filing Indicator Code CLPØ6: 13 CLPØ6: 13 CLPØ6: ZZ

6

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "10.1.2 Data Use by Business Use” Health Care

(10)

Loop Reference Designator

211Ø Composite Medical

Procedure Code SVCØ1-1: N4 SVCØ1-1: N4 SVCØ1-1: N4

Claim Adjustment Group

Code CASØ1: PR CASØ1: PR CASØ1: PR

Claim Adjustment Reason _Code CASØ2: 3 CASØ2: 3 CASØ2: 241

Adjustment Amount CASØ3: 3Ø.ØØ CASØ3: -3Ø.ØØ CASØ3: 3.3Ø

Code CASØ1: CO CASØ1: CO CASØ1: CO

3.2.1 B

USINESS

C

ASE

2.1

Facilities.

The claim example above illustrates transaction sets where a payer made a subsequent correction to a correction

submitted in a previous cycle (Cycle 2). The payer sends a reversal and correction in a subsequent cycle (Cycle 3) to

adjust the Claim Payment Amount due to a change in the Ingredient cost adjustment from $53.93 to $63.93.

The Patient Responsibility amount remains unchanged at $3.3Ø. The Claim Payment Amount has decreased $1Ø.ØØ

from $185.57 to $175.57 resulting in a deduction of $1Ø.ØØ from the LTC Pharmacy Provider.

The total amount paid to the provider reported on the 835 in BPRØ2 for cycle 2 is $1Ø26.7Ø which includes the

$185.57 for this claim. For cycle 3 since the reversal and correction must be reported on the same 835 the total

amount paid reported to the provider is $99Ø.ØØ which includes the reversal of $185.57 and the corrected claim

(1ØØØ.ØØ-185.57+175.57 = 99Ø.ØØ)

Loop Reference Designator Definition Cycle 2 (Correction) Cycle 3 (Reversal) Cycle 3 (Correction) Total Actual Provider Payment

Amount BPRØ2: 1Ø26.7Ø BPRØ2: 99Ø.ØØ BPRØ2: 99Ø.ØØ

21Ø

Ø Claim Submitter's Identifier CLPØ1: 1234589 CLPØ1: 1234589 CLPØ1: 1234589

Patient Responsibility Amount CLPØ5: 3.3Ø CLPØ5: CLPØ5: 3.3Ø

Claim Filing Indicator Code CLPØ6: ZZ CLPØ6: ZZ CLPØ6: 13

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X12/ØØ5Ø1ØX221A1 Health Care Claim Payment/Advice (835)

Loop Reference Designator Definition Cycle 2 (Correction) Cycle 3 (Reversal) Cycle 3 (Correction)

211Ø Composite Medical Procedure Code SVCØ1-1: N4 SVCØ1-1: N4 SVCØ1-1: N4

Procedure Code SVCØ1-2: 123456789Ø1 SVCØ1-2: 123456789Ø

1 SVCØ1-2:

123456789Ø 1

Line Item Provider Payment Amount SVCØ3: 185.57 SVCØ3: -185.57 SVCØ3: 175.57

` DTMØ1: 472 DTMØ1: 472 DTMØ1: 472

Service Date DTMØ2: 2ØØ6Ø7Ø1 DTMØ2: 2Ø111Ø15 DTMØ2: 2ØØ6Ø7Ø1

Claim Adjustment Reason Code CASØ2: 241 CASØ2: 241 CASØ2: 3

3.2.2 B

USINESS

C

ASE

2.2

Facilities.

The claim example

7

below illustrates transaction sets where a payer made a subsequent correction to a correction

submitted in a previous cycle (Cycle 3). The payer sends a reversal and correction in a subsequent cycle (Cycle 4) to

adjust the Patient Responsibility Amount and Claim Payment Amount to reflect a retro LIS adjustment for the patient to

LIS Category 3, copay of $Ø.ØØ

The Patient Responsibility amount has decreased $3.3Ø from $3.3Ø to $Ø.ØØ. The Claim Payment Amount has

increased $3.3Ø from 178.87 to $182.17 resulting in a remittance of $3.3Ø to the LTC Pharmacy.

The total amount paid to the provider reported on the 835 in BPRØ2 for cycle 3 is $99Ø.ØØ which include the $175.57

for this claim. For cycle 4 since the reversal and correction must be reported on the same 835 the total amount paid

reported to the provider is $1ØØ3.3Ø which includes the reversal of $175.57 and the corrected claim amount of

$178.87. Other claim activity = $1ØØØ.ØØ, Reversal = $175.57, Corrected Claim = $178.87

(1ØØØ.ØØ-175.57+178.87 =1ØØ3.3Ø)

Loop Reference Designator

Total Actual Provider _{Payment Amount} BPRØ2: 99Ø.ØØ BPRØ2: 1ØØ3.3Ø BPRØ2: 1ØØ3.3Ø

7

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "10.1.2 Data Use by Business Use” Health Care

(12)

Loop Reference Designator

Patient Responsibility Amount CLPØ5: 3.3Ø CLPØ5: CLPØ5:

211Ø Composite Medical

Procedure Code SVCØ1-1: N4 SVCØ1-1: N4 SVCØ1-1: N4

Amount SVCØ3: 175.57 SVCØ3: -175.57 SVCØ3: 178.87 Quantity SVCØ5: 3Ø SVCØ5: 3Ø SVCØ5: 3Ø ` DTMØ1: 472 DTMØ1: 472 DTMØ1: 472 Service Date DTMØ2: 2ØØ6Ø7Ø1 DTMØ2: 2Ø111Ø15 DTMØ2: 2ØØ6Ø7Ø1

Code CASØ1: PR CASØ1: PR CASØ1:

Code CASØ2: 3 CASØ2: 3 CASØ2:

Adjustment Amount CASØ3: 3.3Ø CASØ3: -3.3Ø CASØ3:

Code CASØ1: CO CASØ1: CO CASØ1: CO

3.3 B

USINESS

C

ASE

3:

M

ULTIPLE

A

DJUSTMENTS IN

O

NE

C

YCLE

Facilities.

On date of service patient had no LIS (Low Income Subsidy).

The claim example

8

cycle (Cycle1). The payer sends a reversal and correction in a subsequent cycle (Cycle 2) to adjust the Patient

copay of $Ø.ØØ AND to adjust the Ingredient Cost Adjustment Amount.

The Patient Responsibility amount has decreased $3Ø.ØØ from $3Ø.ØØ to $Ø.ØØ resulting in an increase in the

Claim Payment Amount of $3Ø.ØØ.

8

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "10.1.2 Data Use by Business Use” Health Care

(13)

The Ingredient Cost Adjustment amount has increased $1Ø.ØØ from $53.93 to $63.93 resulting in a decrease in the

Claim Payment Amount of $1Ø.ØØ.

The Claim Payment Amount has increased $2Ø.ØØ from $158.87 to $178.87 resulting in a remittance of $2Ø.ØØ to

the LTC Pharmacy. ($3Ø.ØØ Copay - $1Ø.ØØ Ingredient Cost)

amount paid reported to the provider is $1Ø2Ø.ØØ which includes the reversal of 158.87 and the corrected claim

(1ØØØ.ØØ-158.87+178.87 =1Ø2Ø.ØØ)

Loop Reference Designator

Amount BPRØ2: 1ØØØ.ØØ BPRØ2: 1Ø2Ø.ØØ BPRØ2: 1Ø2Ø.ØØ

Patient Responsibility Amount CLPØ5: 3Ø.ØØ CLPØ5: CLPØ5:

Claim Adjustment Group Code CASØ1: PR CASØ1: PR CASØ1:

Claim Adjustment Reason Code CASØ2: 3 CASØ2: 3 CASØ2:

Adjustment Amount CASØ3: 3Ø.ØØ CASØ3: -3Ø.ØØ CASØ3:

3.4 B

USINESS

C

ASE

4:

I

NCREASE IN THE

B

ENEFICIARIES

P

ATIENT

R

ESPONSIBILITY

(C

OPAY

)

(14)

Facilities.

On date of service patient had LIS (Low Income Subsidy) Category 2, copay of $3.3Ø

The claim example

9

cycle (Cycle1).

The payer sends a reversal and correction in a subsequent cycle (Cycle 2) to adjust the Patient Responsibility Amount

and Claim Payment Amount to reflect a retro LIS adjustment for the patient to LIS Category 1, copay of $6.3Ø.

The Patient Responsibility amount has increased $3.ØØ from $3.3Ø to $6.3Ø. The Claim Payment Amount has

decreased $3.ØØ from 185.57 to $182.57 resulting in a deduction of $3.ØØ from the LTC Pharmacy. The LTC

Pharmacy will invoice the patient $3.ØØ representing the increase in the patient responsibility amount defined in the

adjustment.

$185.57 for this claim. For cycle 2 since the reversal and correction must be reported on the same 835 the total

amount paid reported to the provider is $997.ØØ which includes the reversal of 185.57 and the corrected claim amount

of $182.57. Other claim activity = $1ØØØ.ØØ, Reversal = $185.57, Corrected Claim = $182.57.

(1ØØØ.ØØ-185.57+182.57 = $997.ØØ).

Pharmacy collects the additional $3 from the patient for the pharmacy to remain whole.

Loop Reference Designator

Amount BPRØ2: 1ØØØ.ØØ BPRØ2: 997.ØØ BPRØ2: 997.ØØ

Patient Responsibility Amount CLPØ5: 3.3Ø CLPØ5: CLPØ5: 6.3Ø

9

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "10.1.2 Data Use by Business Use” Health Care

(15)

Loop Reference Designator

Service Date DTMØ2: 2ØØ6Ø7Ø1 DTMØ2: 2Ø111Ø15 DTMØ2: 2ØØ6Ø7Ø1

Code CASØ2: 3 CASØ2: 3 CASØ2: 241

(16)

Last Updated: August 2Ø12. August 2Ø12. National Council for Prescription Drug Programs 924Ø East Raintree Drive Scottsdale, AZ 8526Ø

Income Subsidy (LICS/LIS) Adjustments Reporting on the

NCPDP Medicare Part D Low Income Cost Sharing/Low Income Subsidy

confidentiality of this information and should utilize the standards accordingly.

subject the user to numerous legal claims.

Publication History:

All rights reserved.

Table of Contents

BUSINESS CASE 4: INCREASE IN THE BENEFICIARIES PATIENT RESPONSIBILITY (COPAY) 13

X12/ØØ5Ø1ØX221A1 Health Care Claim

X12/ØØ5Ø1ØX221A1 Health Care Claim Payment/Advice (835)

adjustment of pharmacy claims using the ØØ5Ø1ØX221A1 to their long term care (LTC) business partners. The

3. ØØ5Ø1ØX221A1 LOW INCOME SUBSIDY (LIS) ADJUSTMENT

Legend:

CLPØ2 – Claim Status Code1

Business Rule: The value of "ZZ" will appear in CLPØ6 if any adjustment to the claim was for LIS. If there was no

LTC Pharmacy has attestation with Plan for limited reimbursement for LIS-eligible enrollees residing in Skilled Nursing

cycle (Cycle1). The payer sends a reversal and correction in a subsequent cycle (Cycle 2) to adjust the Patient

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "Claim Filing Indicator Code” Health Care Claim

<http://www.wpc-edi.com>.

The Patient Responsibility amount has decreased $26.7Ø from $3Ø.ØØ to $3.3Ø (previous adjustment of $23.7Ø paid

amount paid reported to the provider is $1ØØ3.ØØ which includes the reversal of 158.87 and the corrected claim

Loop Reference Designator

USINESS

submitted in a previous cycle (Cycle 2). The payer sends a reversal and correction in a subsequent cycle (Cycle 3) to

The total amount paid to the provider reported on the 835 in BPRØ2 for cycle 2 is $1ØØ3.ØØ which include the

Loop Reference Designator

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "10.1.2 Data Use by Business Use” Health Care

Loop Reference Designator

USINESS

cycle (Cycle1). The payer sends a reversal and correction in a subsequent cycle (Cycle 2) to adjust the Patient

$158.87 for this claim. For cycle 2 since the reversal and correction must be reported on the same 835 the total

Loop Reference Designator

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "10.1.2 Data Use by Business Use” Health Care

Loop Reference Designator

USINESS

submitted in a previous cycle (Cycle 2). The payer sends a reversal and correction in a subsequent cycle (Cycle 3) to

$185.57 for this claim. For cycle 3 since the reversal and correction must be reported on the same 835 the total

X12/ØØ5Ø1ØX221A1 Health Care Claim Payment/Advice (835)

Loop Reference Designator Definition Cycle 2 (Correction) Cycle 3 (Reversal) Cycle 3 (Correction)

` DTMØ1: 472 DTMØ1: 472 DTMØ1: 472

USINESS

submitted in a previous cycle (Cycle 3). The payer sends a reversal and correction in a subsequent cycle (Cycle 4) to

The total amount paid to the provider reported on the 835 in BPRØ2 for cycle 3 is $99Ø.ØØ which include the $175.57

Loop Reference Designator

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "10.1.2 Data Use by Business Use” Health Care

Loop Reference Designator

USINESS

cycle (Cycle1). The payer sends a reversal and correction in a subsequent cycle (Cycle 2) to adjust the Patient

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "10.1.2 Data Use by Business Use” Health Care

The Ingredient Cost Adjustment amount has increased $1Ø.ØØ from $53.93 to $63.93 resulting in a decrease in the

amount paid reported to the provider is $1Ø2Ø.ØØ which includes the reversal of 158.87 and the corrected claim

Loop Reference Designator

USINESS

Facilities.

and Claim Payment Amount to reflect a retro LIS adjustment for the patient to LIS Category 1, copay of $6.3Ø.

$185.57 for this claim. For cycle 2 since the reversal and correction must be reported on the same 835 the total

Loop Reference Designator

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. "10.1.2 Data Use by Business Use” Health Care

Loop Reference Designator