Skip To: Main content|Subnavigation|
Minnesota Department of Human Services MN–ITS User Manual
Advanced Search|  

Pharmacy (NCPDP) Instructions

Revised: 04-03-2015

Review MHCP Billing Policy for general billing requirements and guidance when submitting claims.

Refer to additional billing requirements in the Pharmacy Services section of the MHCP Provider Manual before you submit the claim for services.

Log in to MN–ITS

  • 1. Log in to MN–ITS
  • 2. From the left menu options:
  • a) Select MN–ITS
  • b) Select Submit DDE Pharmacy Claims
  • c) Select Pharmacy claim
  • MN–ITS Pharmacy Screens

    The Pharmacy claim consists of the following screens:

  • • Service Provider/ Cardholder screen
  • • Claim Information screen
  • • Additional Claim Information
  • • Compound Claim Information
  • • COB Other Coverage Code
  • Required/ Situational Fields

  • • Fields that have a single red asterisk are required. Complete all fields with a single red asterisk.
  • • Fields that have double red asterisks are situational, and are required when specific information is needed to further identify the submission of the claim or payment determination. Complete these fields when appropriate for the claim you are submitting.
  • Billing Provider

    The billing provider screen auto-populates with the information in the enrollment profile for the NPI/UMPI used to login to MN–ITS. If changes are needed, use the Change of Enrollment Information to notify MHCP Provider Enrollment.

    Cardholder Entry/Search

    Use the Cardholder ID field to report the recipient who received the service(s) reported on this claim.

    Refer to the table below for instruction and information about each field on this screen.

    Field Name

    Field Description

    Organization

    This field will auto populate with the name of the organization identified by the NPI used at log in.

    Telephone

    This field will auto populate with the telephone number identified in the provider file of the NPI used at login.

    Address Line 1

    This field will auto populate the address or part of the address as entered in the provider file of the NPI used at log in.

    Address Line 2

    This field will auto populate the address or part of the address as entered in the provider file of the NPI used at log in.

    City

    This field will auto populate the city where the organization is located.

    State

    This field will auto populate the state where the organization is located.

    Zip code

    This field will auto populate the zip code where the organization is located.

    Cardholder ID

    Enter the 8-digit MHCP ID number of the recipient of this prescription.

    Birth Date

    Enter the date of birth of the recipient in the 8 digit format (MMDDCCYY).

    Action Buttons

    Select Search to find the recipient information.

    *The search feature will provide the first name, last name and gender of the person associated with the cardholder information entered. This feature does not provider eligibility status.

    Select Delete if the information displayed does not match the name and gender of the cardholder and re-enter the correct cardholder information

    Action Buttons

    • Select Cancel to cancel this claim

    • Select Continue to proceed to the next screen

    Claim Information

    Use the Claim Information screen(s) to report header (claim) level information that will identify the type of claim and details about the service(s). Information entered on the claim information screen will apply to all lines of the claim.

    Refer to the table below for instruction and information about each field on this screen.

    Field Name

    Field Description

    Date of Service

    The date of service will auto-populate with the date the claim is created. If the date of service is different from the date the prescription was dispensed, delete the auto-populated date and Enter the date the prescription was dispensed in the 8-digit MMDDCCYY format.

    Prescriber ID

    Enter the 10 digit NPI of the health care provider who prescribed this medication.

    Prescription/Service
    Reference Number

    Enter the prescription number for this medication.

    Date Prescription Written

    Enter the date the prescription was written in the 8 digit MMDDCCYY format.

    Compound Code

    From the drop down, Select the appropriate option for this claim.

    * If Compound code 2 is selected, a collapsed accordion screen identified as Compound Claim Information will display. You must complete the compound information screen when submitting a compound drug claim to MHCP.

    Product Service ID (NDC)

    Enter the NDC that identifies this drug.

    * For compound drugs, if code 2 was selected for compound code, then this field will be shaded and you will enter in all NDC numbers on the compound screen.

    Fill Number

    Enter the number that identifies the number of “fills” this prescription is (i.e.: 1 = first fill, 2 = second fill).

    Dispense As Written

    From the drop down, Select the appropriate code that indicates whether you followed the prescriber’s instructions regarding generic substitutions.

    Quantity Dispensed

    Enter the number of units dispensed. A decimal point must be placed at the fourth digit from the end followed by three remaining numbers

    *For compound drugs enter the number of finished bags, vials, etc.

    Days’ Supply

    Enter the number of days that this dispensing should last.

    Ingredient Cost Submitted

    Enter the cost of the ingredient for this prescription. Must use a decimal.

    Gross Amount Due

    Enter the total of all costs associated with this claim. Must use a decimal.

    Basis of Cost Determination

    From the drop down, Select the appropriate qualifier that identifies how the cost or submitted charge was determined.

    Usual and Customary Charge

    Enter your usual and customary charge for this medication.

    Other Coverage Code

    When other insurance is available this is a required field.

    From the drop down, Select the appropriate code to identify if the other insurance accepted or denied the claim and what was determined to be the patient responsibility.

    Select 0 or 1 if it is unknown or if other insurance is not available.

    * At the bottom of the screen a collapsed COB Information screen will display if other coverage code 2, 3 or 4 is selected. The COB screen must be completed when other insurance is identified.

    Action Buttons

    Select the appropriate Action Button from the bottom of this screen if no other information needs to be reported on the collapsed accordion screens.

  • Back – will bring you back to the last screen you viewed or entered information
  • Cancel – will delete the entire claim
  • Validate – will allow the claim to go through our system to verify if there are errors on the claim
  • Submit – will submit the claim for processing
  • Collapsed Accordion Screens

    Select the appropriate closed accordion screen at the bottom of this screen to report situational information.

    Depending on the information provided on the claim information screen there are three possible options:

  • Additional Claim Information – Will always display
  • Compound Claim Information – Will display if Compound code 2 is selected
  • COB (Coordination of Benefits) – Will display if other coverage code 2, 3 or 4 is selected. You must submit the claim to the other payer and report the response from the other payer when other insurance is available
  • Additional Claim Information: Select this collapsed accordion screen to report situational information

    Place of Service

    This field in not required, but the provider can use this field to identify the place where a drug or service is dispensed or administered.

    Compound Type

    This field in not required unless billing criteria requires a compound type on this claim.

    If reporting a compound type, from the drop down Select the appropriate compound type.

    Professional Service Code

    This field in not required unless a pharmacist intervention is needed when a conflict code is identified.

    If reporting a professional service code, from the drop down Select the appropriate professional service code.

    Route of Administration

    This field is required when reporting a compound drug claim.

    Enter the SNOMED value that corresponds with the route the compounded prescription is being administered.

    Unit of Measure

    This field in not required unless billing criteria requires the unit of measure to be identified.

    If reporting a unit of measure, Select the appropriate unit of measure from the drop down.

    Special Packaging ID

    This field in not required unless billing criteria requires a special packaging ID on this claim.

    If reporting a special packaging ID, from the drop down Select the appropriate unit of measure.

    Prior Authorization

    When required Enter the 11- digit prior authorization number assigned for this prescription.

    Result of Service Code

    This field is not required unless drug utilization review is necessary.

    Select the appropriate code from the drop down.

    Number of Refills Authorized

    When required enter the number of refills that have been authorized for this prescription.

    Enter the appropriate refill count using a 2-digit format.

    Submission Clarification Code

    This field in not required unless billing criteria requires an explanation of why this prescription is being filled for one of these reasons: Select either of these two reasons from the drop down

  • • If billing for a compound, use value 8 to allow payment for approved ingredients.
  • • Use value 20 to indicate the product is purchased under Section 340B
  • Action Buttons
    Select Add to add the submission clarification code to the claim.

    When the submission clarification code is added, that code will display in the Submission Clarification Description field.

    A Delete button will display next to the submission code entry. Select Delete to remove that entry if the wrong code was selected.

    Diagnosis Code

    When required, Enter the diagnosis code that describes the medical condition that requires the use of this medication.

    Select Add to add the diagnosis code to the claim.

    The diagnosis code will display below the field in the display table.

    Repeat this step to add additional codes. When entering multiple codes enter their codes in order of priority to identify the primary reason the prescription was filled.

    I would just indicate that there can be up to five occurrences. Then add the part of the priority.

    A Delete button will display next to the diagnosis code. Select Delete to remove the entry if the wrong diagnosis code was entered.

    Action Buttons

    Select the appropriate Action Button from the bottom of this screen if no other information needs to be reported on the collapsed accordion screens.

  • Back – will bring you back to the last screen you viewed or entered information
  • Cancel – will delete the entire claim
  • Validate – will allow the claim to go through our system to verify if there are errors on the claim
  • Submit – will submit the claim for processing
  • Compound Claim Information: Select this collapsed accordion screen to report the required fields for a compound drug claim. A compound claim must have two or more ingredients

    Compound Dosage Form Description Code

    Refer to the Compound Drugs section of the MHCP Provider Manual to review billing criteria for billing compound drug claims.

    From the drop down, Select the indicator that describes the type of compound.

    Compound Dispensing Unit Form Indicator

    From the drop down, Select the unit of measure for this compound.

    Compound drug claim information - Repeat the fields below for each of the ingredients being sent.

    Product ID

    Enter the 11-digit NDC for each ingredient of the compound. Enter the main ingredient first, even if it has been entered on the claim information screen.

    Quantity

    Enter the total quantity of units used of the NDC that was reported in the product ID field. A decimal point must be placed at the fourth digit from the end followed by three remaining numbers.

    Drug Cost

    Enter the total cost of the NDC reported in the Product ID field for this drug.

    Basis of Cost Determination

    From the drop down, Select the appropriate qualifier that identifies how the cost or submitted charge was determined.

    Component Count

    This field will auto-fill for each line entry of the compound.

    *Maximum count is 25

    Action Buttons

    Select Add to add the compound information for each ingredient.

    When the compound information is added to the claim, the information will display in a table below the compound ingredient fields with the information that was added. A Delete button will display after each entry.

    Select the Delete button to remove an entry if the information displayed is not needed or is incorrect. If needed, enter the correct information and add the new information to the claim.

    If no other information needs to be reported on other collapsed accordion screens, Select the appropriate Action Button from bottom of the screen

  • Back – will bring you back to the last screen you viewed or entered information
  • Cancel – will delete the entire claim
  • Validate – will allow the claim to go through our system to verify if there are errors on the claim
  • Submit – will submit the claim for processing.
  • Coordination of Benefits (COB): Select this collapsed accordion screen to report other payer information

    Coverage Type

    Refer to the Billing Coordination of Benefits (COB) section of the MHCP Provider Manual to review billing criteria and the Minnesota Medicaid Version of the D.0) NCPDP Payer Sheets

    From the drop down, Select the other payer’s level of responsibility for this cardholder (i.e., primary, secondary).

    ID

    Enter ID of the payer.

    *This ID is often called the “Carrier ID” and can be found on the eligibility response in MN–ITS.

    Date

    Enter the date the other payer processed this claim.

    Other Payer Amount - Repeat the fields listed below for each qualifier identified by the other payer

    Paid Qualifier

    From the drop down, Select the qualifier that was indicated by the other payer that describes the benefit or additional cost that was paid by the other payer.

    Paid

    Enter the amount that was paid by the other payer for the paid amount qualifier.

    Paid Count

    This field will auto-populate the numeric count for each qualifier and dollar amount entered as paid.

    Other Payer Reject - *Repeat the fields listed below for each reject code sent by the other payer

    Reject Code

    Enter the reject code(s) that were indicted by the other payer, describing the reason the claim was denied.

    Count

    This field will auto-populate the numeric count for each reject code entered.

    Other Payer Patient Responsibility - *Repeat the fields listed below for each qualifier identified and sent by the other payer.

    Amount Qualifier

    From the drop down, Select the qualifier that was indicated by the other payer that describes the amount being applied as patient responsibility.

    Amount

    Enter the dollar amount that was applied to the patient responsibility.

    Amount Count

    This field will populate the numeric count for each qualifier and dollar amount entered as patient responsibility.

    Action Buttons

    Select the appropriate Action if you need to remove the COB entry or add another payer.

  • Delete this Other Payer – will delete the other payer information entered on the COB screen. If the COB entry was deleted because it was entered in error and is being removed from the claim, you must also change the other coverage code on the Claim Information screen and remove/delete the route of administration from the Additional Claim information screen
  • Add Other Payer – will allow you to start a new screen to report additional payers if necessary
  • If no other information needs to be reported on other collapsed accordion screens, Select the appropriate Action Button from bottom of the screen

  • Back – will bring you back to the last screen you viewed or entered information
  • Cancel – will delete the entire claim
  • Validate – will allow the claim to go through our system to verify if there are errors on the claim
  • Submit – will submit the claim for processing
  • MN–ITS Help – Pharmacy (NCPDP): Response

    The Claim Status Submission contains the status of your claim.

  • • Submission Response – will provide the following information
  • • Payer Name and tax ID number, MHCP Provider Call Center & phone numbers
  • • Provider – NPI number and name of billing provider (this will be coming in future enhancements)
  • • Subscriber – ID number and name
  • • Claim information – brief recap of your submitted claim with the following:
  • • Bill Type – Pharmacy
  • • Claim Service Period – date being billed
  • • Status Information Effective Date – date of service
  • • Payer Claim Control Number – NA for pharmacy
  • • Total Submitted Charge providers usual and customary
  • • Pharmacy Prescription Number – Rx number given by provider
  • • Total Reimbursement Amount – total amount that MHCP pays out
  • • Adjudication Date – date the claim was adjudicated in MMIS
  • • Remittance Date – N/A
  • • Trace Number – NA for Pharmacy
  • • Claim Status Category Code & Claim Status Code – refer to Washington Publishing Company; this will inform the submitter if the claim is paid, denied or suspended
  • • Service line information – will provide information on the following:
  • • Line Number
  • • Line Submitted Charge
  • • Line Units
  • • Line Service Dates
  • • Line Reimburse Amount
  • • Status Information Effective Date – details go here
  • • Line Claim Status Category Code and Claim Status Code – refer to Washington Publishing Company, for the codes definitions.
  • The table below describes the individual fields on the Response screen.

    Field Name*

    Field Description

    Copy

    Selecting the copy button will allow the user to copy the claim after submission. The user then can submit another claim for a different date of service or a different prescription and a different prescription number.

    Note: This function is not available after the “Close” button has been selected.

    Reversal

    Selection the Reversal button will allow the user to take back the claim just submitted.

    Note: This function is not available on denied claims or once the “Close” button has been selected.

    Close

    Selecting the close button will allow the user to close out of this claim.

    MN–ITS Help – Pharmacy (NCPDP): Reversal

    In order to reverse a claim you must have the “Submit DDE Pharmacy Claims” If this function does not appear the administrator needs to add the “claim/reversal” option that is located in User Administration.

    The Reversal Claim gives an overview of the claim that is in process of being reversed.

    Service Provider Information

  • • Organization – organization identified by the NPI used at log in
  • • Telephone – telephone number identified in the provider file of the NPI used at login
  • • Address Line 1– address or part of the address as entered in the provider file of the NPI used at log in
  • • Address Line 2 – address or part of the address as entered in the provider file of the NPI used at log in
  • • City – city where the organization is located
  • • State – state where the organization is located
  • • Zip – zip code where the organization is located
  • Reversal Claim Information

  • • Cardholder ID – 8-digit MHCP ID number of the recipient of this prescription
  • • Date of Service – date the prescription was dispensed in the 8-digit MMDDCCYY format
  • • Prescription/Service Reference Number – prescription number for this medication
  • Field Name*

    Field Description

    Cancel

    Selecting cancel will bring provider back to the claim and the claim will not be reversed.

    Submit

    Selecting Submit will reverse the claim.

    Rate/Report this pageReport/Rate this page

    © 2017 Minnesota Department of Human Services Updated: 4/3/15 3:23 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 4/3/15 3:23 PM