Payment and Claims Info

Hawaii Payment Cycles

Hawaii's payment cycle is weekly and payments include claims processed from Wednesday through Thursday. Please see example below.

Wednesday – Thursday
10/18/2006 - 10/26/2006

Sample Remittance Advice



      (2)  CLINICAL PHARMACY CONSULTANTS                (3)  CHECK NUMBER:    0552198

           PONAHAWAI PHARMACY                         (4)  REMITTANCE NO.:     647697

           670 PONAHWAI ST SUITE 213                 (5)  REMITTANCE DATE: 09/12/2001

           HILO               HI 96720                               PAGE:          1




    RX NO/   DATE  PARTICIPANT NAME/           NDC            UNITS  SUB CHG    PD AMT   SRC


                                                  (12)        (13)   (14)      (15)   (16)

(8) 6279569 091201   SMITH  (10)          G R 59572010593    112.000 1,040.90    954.29  B

(9) 01255313893510 THALOMID 50MG CAPSULE (11)


    6279569 091201   SMITH                G R 59572010593    112.000 1,040.90-   954.29- B

    01255313920111 THALOMID 50MG CAPSULE


    6279569 091201   SMITH                G R 59572010593    168.000 1,557.36  1,429.09  B

    01255313940010 THALOMID 50MG CAPSULE


    6282374 090601   JONES                P   00093226801     30.000    10.59      9.47  F

    01249312458210 AMOXICILLIN 250MG TAB CHEW


    6282374 090601   JONES                P   00093226801     30.000    10.59-     9.47- F

    01249312502411 AMOXICILLIN 250MG TAB CHEW


    2282354 090601   DOE                  J   00007351320      0.000    35.58      0.00  D

    01249310075910 DEXEDRINE SPANSULE 10MG     (17)  PRIOR AUTHZ REQ'D 800/365-4944


    6282374 090601   JONES                P   00007351320      0.000    35.58      0.00  D

    01249312527910 DEXEDRINE SPANSULE 10MG           PRIOR AUTHZ REQ'D 800/365-4944


    6282374 090601   JONES                P   00007351320      0.000    35.58      0.00  D

    01249312551610 DEXEDRINE SPANSULE 10MG           PRIOR AUTHZ REQ'D 800/365-4944


    6283085 091201   SMITH                G R 59572010593      0.000 1,557.36      0.00  D

    01255313145310 THALOMID 50MG CAPSULE             PRIOR AUTHZ REQ'D 800/365-4944



                        5 TOTAL PRESCRIPTIONS PAID      TOTAL PAID:       1,429.09 (18)


                        4 TOTAL PRESCRIPTIONS DENIED



Above is a sample of what an ACS RA (Remittance Advice) looks like.  Each and every claim

(paid AND denied) that the pharmacy transmitted during a cycle will appear on the RA.


The prescriptions are listed in the following order:


1.       Paid claims appear first, in cardholder ID order, then by TCN.  Cardholder ID’s do not

      appear on the remittance, but claims are listed in ascending cardholder ID order.  Then

      within a cardholder, claims are sorted by TCN order.


2.       After the paid claims, the denied claims appear, also in Cardholder ID order an then by TCN. 

      If a pharmacist complains about not seeing a claim for which he got a paid response online,

      and he is only seeing the denied one, please ask him to look in the front of the RA.


Following is a descriptive listing of the fields on an RA (Remittance Advice):

1)      Name of Client (we create a check and RA for each client that the pharmacy has dispensed.

2)    Name of Pharmacy and payment address

3)    Check Number of the check attached to the RA.

4)    Remittance Number

5)    Remittance Date (should match the check date)

6)    Pharmacy name (listed here again if check is paying more than one pharmacy)

7)    NABP of the pharmacy that submitted the claim.

8)    Rx number of the claim.

9)    The TCN transmitted back to the pharmacy.

10)Last name of Recipient

11)Name of the drug on the claim.

12)NDC of the drug on the claim.

13)The Submitted Units (quantity) of the claim.

14)The Submitted charge (the amount the pharmacy submitted) Total Charge from the

            claim screen.

15)Paid Amount of the claim.  From the amount paid on the claim screen.

16)SRC or Pricing Source of the claim.  (see the legend at the bottom of the page.)

            V means State MAC was applied.

17)Reason for no payment.  Any time a claim pays zero to the pharmacy, there will be a reason.

18)Total amount of the check attached to this RA.



 B-AWP LESS %   D-DENIED   S-Submitted  6-Medicaid AWP   F-FEDMAC   V-State MAC