On-line Claim Submission Procedure Overview
Participating Pharmacies are required to submit all claims on-line to MedImpact for all Pharmaceutical Services provided to a Member. The information needed to process claims on-line is:

Processor Control Number: 99500
Bank Identification Number: 003585

This includes Pharmaceutical Services for which:

• The Pharmacy Payment is less than the Copayment, Coinsurance, Deductible and/or the Ancillary Charge.
• The Copayment, Coinsurance, Deductible and/or the Ancillary Charge equal the payment for the Pharmaceutical Service.
• The payment may be applied to a Deductible.

On-line Claim Submission Procedures
Pharmacy must use the NCPDP Telecommunication Standard Version 5.1 or other format designated in writing by Medica.

Input the entire 14 or 15-digit identification number and 2-digit dependent code into the Member identification field on your electronic claim screen. Make sure you select the appropriate Members' dependent code from the ID card.

If your system requires you to input a specific dependent code value into a separate field, place the first 14 digits of the member number in the member number field and the last two digits of the member number in the dependent code field. MedImpact's system will merge these two fields together when processing the claim.

Complete all required NCPDP fields and transmit the claim electronically to MedImpact. Pharmacy has 180 days from the date of service to submit the claim on-line to MedImpact for adjudication.

Pharmacy is required to submit its Customary Charge with each transaction.

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On-line Availability

• The MedImpact on-line service is available 24-hours-a-day, 365 days per year.

In the event that the MedImpact on-line system is down, the Pharmacy:

• Should contact MedImpact to verify eligibility and coverage of Pharmaceutical Service.
• Should hold the claim until the on-line system becomes available.
• Has 180 days from the date of service to process a claim through the on-line system.

Dispense As Written (DAW)

• MedImpact's system recognizes all nine (9) of the nine DAW codes established by NCPDP.
• Pharmacy must submit the proper DAW code to receive the appropriate reimbursement.

MedImpact's on-line claim adjudication system accepts DAW codes 3 -9 in addition to those listed below, however, they are treated as DAW = 0. If no DAW code is entered, MedImpact will interpret that as DAW = 0.

The DAW codes recognized by MedImpact's on-line system are:

• DAW = 0 No DAW indicated (generic or single source brand).
• DAW = 1 Dispense As Written By Participating Provider.

The Participating Provider has indicated on the prescription the handwritten words "Dispense as Written," the handwritten letters "DAW," or equivalent indication as may be required by applicable laws or regulations to indicate the same intention

Submit DAW = 1

• If "Dispense as Written" is indicated by Participating Provider on the hard copy of the prescription.
• If Participating Provider has verbally indicated "Dispense as Written" on a telephoned prescription.
  • The pharmacist must indicate on the prescription the Participating Provider's verbal instruction to "Dispense as Written."
• Computer generated prescriptions maintained at Pharmacy must indicate the Participating Provider's instruction to "Dispense As Written."
• DAW = 2 Substitution Is Allowed, Member Requested Brand.

Submit DAW = 2

• Participating Provider has indicated, in a manner consistent with applicable laws or regulations, that generic substitution is permitted, but the Member has requested a brand name Pharmaceutical Service.
• The Member may be responsible for the additional cost incurred for receiving a brand name Pharmaceutical Service when a generic is available.
• DAW = 7 Substitution Not Allowed - Brand Drug Mandated by law.
  Claims submitted with a code of DAW = 7 on Pharmaceutical Services that are subject to MAC pricing, will be rejected on-line by MedImpact with NCPDP reject code 22:

Maximum Allowable Cost (MAC) List

• Includes products reimbursed at a generic product level established byMedimpact.
• Is subject to periodic review and modification.
• Is reflected by MedImpact's on line claim adjudication system.

MedImpact does not back date, or apply updated pricing to unit costs that were changed prior to the current pricing.

Ancillary Charge

• Medica may require the Member to pay an Ancillary Charge in addition to their Copayment, when a brand name Pharmaceutical Service is dispensed in non-conformance with the Medica MAC List.
• The Ancillary Charge is the difference between the Maximum Allowable Cost of the Pharmaceutical Service, as listed on the MedImpact MAC List, and the calculated reimbursement rate of the product dispensed.
• MedImpact's on-line claim adjudication system automatically calculates the MAC price and Ancillary Charges where applicable. Refer to the on-line system to determine if Ancillary Charges apply.

MAC Benefit Options
A Member's Benefit Contract may have one of the following types of MAC benefits:

• Voluntary MAC
• Restricted MAC
• Mandatory MAC

Copayment, Coinsurance or Deductible Charge
The Copayment, Coinsurance or Deductible Charge is an amount, specified in the Member's Benefit Contract that the Member is required to pay the pharmacy when Pharmaceutical Services are provided.

When Pharmacy submits claims on-line, MedImpact will relay the appropriate Copayment, Coinsurance or Deductible to be collected from the Member for the Pharmaceutical Service provided.

Unless otherwise communicated by MedImpact's on-line claim adjudication system, Pharmacy is to collect only the following charges from a Member:

• If the claim amount exceeds the Copayment, Coinsurance or Deductible, Pharmacy collects only the amount of the Copayment, Coinsurance or Deductible Charge.
• If the claim amount or Pharmacy's Customary Charge is less than the Copayment, Coinsurance or Deductible, Pharmacy collects the Pharmacy's Customary Charge for the Pharmaceutical Service.
• If the Member has incurred an Ancillary Charge, Pharmacy collects the Copayment, Coinsurance or Deductible plus the Ancillary Charge.
• If the Pharmaceutical Service is not covered under the Member's Benefit Contract, Pharmacy collects the Customary Charge for the Pharmaceutical Service.