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Related post: Pharmacists must enter the member�s correct date of birth on each claim. If a claim is
rejected due to an incorrect date of birth (Argus reject code 91), please contact PHP
Provider Services at 800-578-0775 to verify the member�s date of birth.
Members should be asked to present their PHP member ID card at each visit.
Remember, possession of an ID card does not guarantee eligibility for benefits
The following is a sample illustration of the PHP member ID card:
Certain PHP members are restricted to receiving services from a particular pharmacy
and/or prescriber group as part of PHP�s Lock-In Program.
If the pharmacy and/or prescriber is specifically assigned or �locked in� to the member�s
record, Argus will return a reject message indicating this lock-in exists. This applies to
all therapeutic classes of medications.
If you have any questions about this program, please contact our Lock-In Coordinator at
502-585-7947 or write to:
305 West Broadway, 3 Floor
Please refer to the Fraud, Waste, and Abuse section of this manual for instructions on
how to report suspected misuse of the PHP prescription benefit, or member or store
personnel fraud and/or abuse.
Certain PHP members have prescription copayment requirements. The pharmacy will
be made aware of any copayment responsibility when the claim is adjudicated.
However, if the member is unable to make the copayment, the pharmacy is obligated to
fill the prescription and collect the copayment later. The following members do not
have a copayment requirement:
" Members under the age of 18 years
" Members receiving services within the first 60 days after delivery of a baby
" Members in a nursing facility
" Members in a personal care home
" Members in an intermediate care facility for people with mental retardation
" A foster child in state custody
" An American Indian or Alaskan native served through KCHIP
" Members in hospice care
If the situation arises where the member should not be charged a copay due to one of
the above situations or is unable to make the copayment, please enter code 292000 in
the prior authorization field.
If you need assistance processing a copay override claim, please contact the
PerformRx Help Desk Department at 800-578-0898.
POINT OF SERVICE (POS) POLICIES
Processing Numbers/Argus Plan Code Requirements
The following are mandatory claim processing coding requirements for all pharmacy
" Argus BIN number: 600428;
" Processor control number 02920000.
The pharmacy should process the PHP Member ID number as shown on the member�s
ID card. No prefix or suffix zeroes need to be added. A group number and a line
number are not required for claim submissions and should not be submitted with a
Pharmacies are required to submit PHP claims electronically to Argus Health Systems
(see also Coordination of Benefits Procedure).
Pharmacies can submit and reverse claims online up to 30 days from the original date
of service. The pharmacy must conduct due diligence to ensure that prescription drug
claims not received by the member are reversed within 30 days of the initial fill date.
Claim reversals are indicated in cases where a prescription claim was adjudicated but
never received by an eligible member. All prescriptions not received by eligible
members must be returned to stock within 30 days of processing and must be
If the pharmacy is unable to completely process a reversal online, the pharmacy should
call the PerformRx Help Desk at 800-578-0898 for assistance.
If a member receives only a partial amount of his/her covered prescription, the
pharmacy must modify the claim via the Argus OnLine System within 14 days to
accurately represent the quantity of medication received and billed. Pharmacies will be
audited for claims reversals.
If a pharmacy attempts and is unable to submit a claim for reimbursement electronically
through Argus, then the pharmacy may submit a paper universal claim form containing
all the required NCPDP claims submission fields. Claims should be mailed to the
For assistance with claims submission, contact the PerformRx Help Desk.
National Prescriber Identifier (NPI)
PerformRx, in accordance with the Centers for Medicare & Medicaid Services (CMS)
regulations and guidance, requires all of its contracted pharmacies to process pharmacy
prescription claims using the prescriber�s National Provider Identifier (NPI).
If a member presents a prescription without the prescriber�s NPI, please:
1. Call the prescriber�s office to request the NPI; or
2. Obtain the prescriber�s NPI from the NPI registry web page:
Prescriber ID Prescriber NPI
Prescriber ID Qualifier 01
" If a valid prescriber NPI is not used in the processing of a pharmacy claim, then
the pharmacy will receive the reject code �invalid prescriber ID.�
" Pharmacies substituting a pharmacy NPI as a prescriber NPI on pharmacy
claims will not be accepted.
If you have any questions/concerns regarding claims submission using an NPI, please
call the Buy Diclofenac Potassium PerformRx Pharmacy Help Desk at 800-578-0898.
Dispense As Written (DAW) Codes
Argus supports the standard NCPDP Dispense As Written (DAW) Product Service
Codes. To ensure accurate reimbursement and avoid audit issues, always use the
correct DAW codes when you submit a claim. The DAW codes recognized and
accepted by the Argus POS Claims processing system are 0, 1, 5 and 8.
The following codes are accepted by PerformRx :
DAW 0: No Dispense as Written (Substitution Allowed)
DAW 1: Brand requested by physician requires prior authorization
DAW 5: Brand Product selected as generic
(Pharmacy reimbursement will be at Plan Maximum Allowable Cost)
DAW 8: Product Not Available (May only be used when generic products are not
available in the market place.)
DAW code usage will be strictly monitored.
Remember to contact the prescriber to see if a generic drug can be dispensed, and
always include the correct DAW code when you submit a claim.
Pharmacy signature log records and/ or electronic facsimile signatures are expected to
be kept on file in accordance with the standard pharmacy practice, state and federal
guidelines and laws. The signature log (includes delivered prescriptions) must be kept
by the pharmacy for Generic Diclofenac Potassium a period corresponding to the state pharmacy laws in which the
pharmacy is located for retaining prescription hard copies. Signature log format should
" Prescription/medication Reference Number
" Date medications were picked up, and or delivered to a member
" The signature of the member to whom the prescription was dispensed, or the
DAW code usage will be strictly monitored.
Signature logs and/or electronic facsimile signatures must be retrievable for in-store or
desktop audits upon request or written notice. Pharmacies are not entitled to payment
for any claim for which there is no signature of the eligible person or authorized
representative on the Third Party Signature Claim Log.
COORDINATION OF BENEFITS (COB)
Federal and State Requirements
As an administrator of Kentucky Medicaid benefits, PHP is required to comply with
various regulations mandated by the Kentucky Department for Medicaid Services
(DMS). This includes regulations regarding third party liability.
Because PHP is a Kentucky Medicaid plan, PHP is always considered the payor of
last resort. Therefore, DMS continuously evaluates if PHP members have other
insurance, and notifies the Plan when other primary carriers are found. Once the
Plan has been notified, PHP is required to recover any primary payments.
If a PHP member has other primary insurance, the pharmacy must bill the primary
Bill PHP As a Secondary Insurer
After filing an initial claim to the primary insurer, pharmacies should submit a secondary
COB claim for the remaining unpaid copayment portion to PerformRx.
The claim will fully adjudicate and PHP will pay the difference between what the primary
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