KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL. Pharmacy

Transcription

1 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL Pharmacy

2 PART II Introduction Section BILLING INSTRUCTIONS Page 7000 Pharmacy Billing Instructions Submission of Claim Pharmacy Billing Information BENEFITS AND LIMITATIONS 8100 Copayment MediKan Medicaid Appendix I NCPDP reject codes Forms Section

3 PART II This is the provider specific section of the manual. This section (Part II) is designed to provide information and instructions specific to pharmacy providers. It is divided into two subsections: Billing Instructions and Benefits and Limitations. The Billing Instructions subsection gives an example of the billing form applicable to pharmacy services. Directions for completing and submitting a paper claim are provided. The claim form is provided in the forms section at the end of this manual. The Benefits and Limitations subsection defines specific aspects of the scope of pharmacy services allowed within the Kansas Medical Assistance Program. HIPAA Compliance As a participant in the Kansas Medical Assistance program, providers are required to comply with compliance reviews and complaint investigations conducted by the Secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. The provider is required to provide the same forms of access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider shall not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

4 7000. Updated 08/08 PHARMACY BILLING INSTRUCTIONS Pharmacy providers may contact the Pharmacy Helpdesk toll-free number for assistance with pharmacy claims questions at Introduction to the Pharmacy Claim Form Pharmacy providers must use the Pharmacy Claim Form when requesting payment for items provided under KMAP (unless submitting electronically). An example of the claim form is shown in the Forms section at the end of this manual. Instructions for completing this claim form are included in the following pages. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. Copies of the Pharmacy Claim Form may be ordered through EDS. Refer to Section 1100 in the General Introduction Manual. For paper claim submissions for compounds, bill only one compound prescription per paper claim; do not mix compound claims with noncompound claims. Completing the Pharmacy Paper Claim Form Field 1 Field 2 Field 3 Field 4 Field 5 Field 6 Beneficiary Last Name: Enter beneficiary's last name. First Name Enter first three characters of the beneficiary's first name. Beneficiary Identification Number Enter the 11-digit number from beneficiary's State of Kansas Medical Card medical ID card. DO NOT RECORD THE PROGRAM NUMBER. Nursing Home If appropriate, enter the correct indicator: Y = Yes N = No KAN Be Healthy Leave blank (automated). Other Insurance This field represents insurance information. Valid entries in this field are: Y = If the beneficiary has other health insurance enter "Y" and indicate the amount paid in field 16 (remarks) N = No other insurance X = Insurance denied R = No response from insurance BILLING INSTRUCTIONS 7-1

5 7000. Updated 03/08 Field 7 Field 8 Field 9 Field 10 Prescription Number: Enter the 7-digit prescription number assigned by the pharmacy. Prescribing Physician Medicaid Number: As of April 1, 2008, KMAP requires pharmacy providers to submit the prescribing provider s unique national provider identifier (NPI) or KMAP provider number. A KMAP provider number can only be used if the pharmacy makes a good faith effort to obtain a prescribing provider s NPI and is unsuccessful. As of June 3, 2005 KMAP has requested that pharmacy providers submit the prescribing provider s Drug Enforcement Administration (DEA) number in the prescriber identification field for pharmacy claims. The edit to monitor use of the DEA number is set to pay and list so that pharmacy claims will not deny if a DEA number cannot be obtained. Please use the prescribing provider s DEA number when it is available to assist KMAP in identifying the prescribing provider on pharmacy claims When a prescribing provider s DEA number is not available, KMAP allows a dummy number of AB Date Dispensed: Enter the date the drug was dispensed in MM/DD/YY format. National Drug Code: Enter the 11-digit NDC number assigned to the product actually dispensed. (The last two digits of the NDC number are indicative of package size.) It is critical that each claim reflects the NDC that appears on the drug package being dispensed. NDCs must be given in standard 11-digit format. In cases where the NDC has only three digits in the "product" section (center digits), it is necessary to fill this field to four digits by preceding the three digits with a zero. Field 11 Refill Code: Enter the number of times the prescription has been filled. Enter "00" for original and "01" through "99" for refills. BILLING INSTRUCTIONS 7-2

6 7000 Updated 9/06 Field 12 Metric Quantity: Enter number of tablets or capsules dispensed, number of grams of ointments or powders, or number of cc's of liquids. For claims submitted on and after 10/16/03, rounding up to the nearest whole number will not be accepted. The actual decimal amount must be entered. Do not insert descriptive designations such as "cc's", "Gm." or "each". Field 13 Field 14 Days Supply: Estimate in days the duration of this prescription supply. Diagnosis/Reference Not required unless for one of the following drugs/drug classes Legend prenatal vitamins Partial fill of a C-II prescription for beneficiaries in long-term care facilities or with a medical diagnosis of terminal illness Certain amphetamines, amphetamine-mixtures and amphetamine-like drugs Modafinil (Provigil ) Gabapentin (Neurontin ) Pregabalin (Lyrica ) For allowable diagnosis codes and coverage information see each drug/drug class in the Benefit Limitations section of the pharmacy manual. NOTE: These drugs are not covered for diagnoses other than what is specified. Field 15 Total Charge: This field represents the Usual and Customary total charge of the item billed. This amount should always reflect the Usual and Customary total charge. When a claim is submitted to a third party payer and payment is received, submit to KMAP the same charge that was submitted to the insurance carrier. BILLING INSTRUCTIONS 7-3

7 7000. Updated 04/08 Field 16 Field 17 Field 19 Field 20 Remarks: When adding a remark, identify the line number of the claim that corresponds to the remark. (The Line field is on the left-hand side of the pharmacy claim form.) This field is used to: 1. Indicate insurance carrier and the payment made. (When listing the insurance payments in this field, use the same number as designated in the beneficiary field to indicate the claim that goes with the payment.) 2. Enter the original ICN number from previously submitted claims being resubmitted, if applicable. 3. Enter the approved PA number, if applicable. 4. Identify which lines are part of a compound drug. For each claim (line) that is to process as a compound, the word compound is to be clearly written. It is helpful to state which claims (lines) belong to the same compound. For example "Lines are part of the same compound." 5. Enter a Submission Clarification Code Value, if applicable. For example, write Submission Clarification Code: XX. Total Amount Billed: Total of detail line items billed. Provider Name and Number: Enter the name, address, and NPI or 10-digit Medicaid provider number of the billing provider. Signature: Read statement on claim form and sign. Phrase "signature on file" is acceptable. Provider s name typed or stamped is acceptable. Field 21 Date: Enter the date the form was signed. SUBMISSION OF CLAIM: Send completed claim to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas BILLING INSTRUCTIONS 7-4

8 7010. Updated 03/08 PHARMACY BILLING INFORMATION Compound Drug Claims Compound drug claims may be submitted on the pharmacy claim form or via POS (on-line). Only one dispensing fee will be allowed per compound. Only one co-payment fee will be assessed (if applicable) per compound. The first NDC entered for a compound will be considered the primary ingredient. If any NDC in the compound is not covered, the entire compound will deny. Providers may resubmit the compound without the non-covered NDC(s). Claims identified as a compound but which contain only one ingredient will not be allowed a dispensing fee. If billing for a single NDC compound do not identify the claim as a compound. For compound submissions using the paper pharmacy claim form, use the following steps: Enter each NDC making up the compound as a single line, starting with the NDC considered to be the primary ingredient. If you are submitting more than 10 lines (NDCs) for the same compound, staple the paper claim forms together and note which NDC is the primary ingredient. Fields 1-11: Complete the same as for any pharmacy claim. NOTE: Field 7 (Rx number) will be the same for all lines within the same compound. Field 12: Enter the metric quantity for the NDC on this individual line only; not the total quantity for the entire compound. Fields 13-14: Complete the same as for any pharmacy claim. Field 15: Enter the charge for the NDC on this individual line only; not the total quantity for the entire compound. The charge for the primary (first) ingredient should include a dispensing fee in addition to the drug cost. Field 16: If both of the following conditions apply, be sure to separate these in this field. A) For each claim (line) that is to process as a compound, the word Compound is to be clearly written. It is helpful to state which claims (lines) belong to the same compound. For example "Lines are part of the same compound." B) For a compound where the primary insurance has made a payment, the line number(s) must be indicated along with the insurance carrier and payment made. Remember to mark Field 6 accordingly. Fields 17-21: Complete the same as for any pharmacy claim. Adjustments and Reversals: There will no longer be a limitation for point of sale (POS) reversal transactions or Internet adjustments to reverse or void pharmacy claims based on dispense date. However, providers must still follow the 12- and 24-month timely filing requirements outlined in Section 5100 of the General Billing Provider Manual. BILLING INSTRUCTIONS 7-5

9 7010. Updated 04/08 Medicare Part B Pharmacy providers are required to bill Healthcare Common Procedure Coding System (HCPCS) codes and common procedural terminology (CPT) codes on Medicare Part B designated drugs for Medicare Part B beneficiaries. Providers must be enrolled as a DME provider and supply KMAP with the provider s Medicare provider number so that the claims will automatically cross over from Medicare. This process must be followed for the coinsurance and deductible to be considered for payment. Refer to the Durable Medical Equipment Provider Manual Section 7000 for detailed billing instructions. To process these claims correctly, the claim must be billed with only one detail. If more than one detail is billed, the claim will be denied. Medicare Part D Copay Assistance KMAP provides copay assistance to beneficiaries who have both full Medicare Part D entitlement and one of the following: Title XIX Medicaid (TXIX) Medical Needy with no spenddown or spenddown already met The Medicare Part D Copay Assistance does not occur automatically with the submission of the claim to the Medicare D drug plan. Billing and payment for a beneficiary who has full dual eligibility for Medicare Part D copay is available via point of sale (POS) to KMAP only. KMAP pharmacy providers are reimbursed according to the Medicare Part D copay amount billed minus any KMAP copay and the days supply on the claim as listed below: Up to $5.60 for a 1- to 30-day supply Up to $10.70 for a 31- to 60-day supply Up to $16.05 for a 61- to 90-day supply Points to Note Regarding Medicare Part D KMAP will deny Medicare Part D copay claims submitted with a days supply greater than 90. KMAP will deny Medicare Part D copay claims submitted for a beneficiary not recognized with full dual eligibility. KMAP assistance with the Medicare Part D copay is the lesser of the Medicare Part D copay versus the maximum reimbursement per day s supply. For example, if the Medicare Part D copay is $3.45 for a 30-day supply, KMAP will pay up to $3.45 (and not $5.60) minus any KMAP copay. If the Medicare Part D copay is $5.60 for a 30-day supply, KMAP will pay $5.60 minus any KMAP copay. Instances may occur where beneficiaries have Medicare Part D copay amounts greater than the standard allowed. Several variables could cause this situation. For instance, the Prescription Drug Plan (PDP) does not have the beneficiary coded with full dual eligibility. Providers should continue to follow the current process for resolving these issues. BILLING INSTRUCTIONS 7-6

10 7010. Updated 04/08 Instances may occur where KMAP s assistance with the Medicare Part D copay is reduced to zero or to a low amount (such as $0.10) due to the KMAP copay. In this situation, you are not required to submit the copay assistance claim to KMAP. However, if you decline to submit it, this must be considered a write-off. The beneficiary is not to be charged the KMAP assistance portion of the copay. How to Bill the Medicare Part D Copay Billing and payment for a beneficiary eligible for Medicare Part D copay is available via point of sale (POS) only. KMAP pharmacy providers need to contact their software vendors to assess if any changes are needed. Vendors will find the current Kansas Medical Assistance Program Management Information System Interface Specifications NCPDP Version 1.1 and 5.1 Transaction Payer Sheets document helpful. This is listed as NCPDP and located at The following NCPDP fields and associated values must be part of a Medicare Part D copay submission to KMAP: Claim Segment Other Coverage Code (308-C8) = 8 (Claim is billing for a co-pay) Pricing Segment Other Amount Claimed Submitted Count (478-H7) = 1 (One occurrence) Other Amount Claimed Submitted Qualifier (479-H8) = 99 (Other) Other Amount Claimed Submitted (480-H9) = Medicare Part D copay amount Gross Amount Due (430-DU) = Medicare Part D copay amount The above fields and associated values for a Medicare Part D copay submission complies with the adopted recommendation from the May 2001 Telecommunication Work Group. Contact your software vendor for additional information on all fields to submit this type of transaction. Payment Response from KMAP for a Medicare Part D Copay KMAP providers can expect to receive the KMAP amount paid for the Medicare Part D copay in the Total Amount Paid field (509-F9). Any remaining patient responsibility or KMAP copay will be returned in the Patient Pay Amount field (505-F5). Primary Insurance Other Than Medicare Part D KMAP continues to consider payment of any unpaid allowed charges by the primary insurance and not the copay from the primary insurance. Therefore, no changes are required to the current billing process when pharmacy providers bill KMAP primary insurance paid claims (excluding Medicare Part D as primary). KMAP s continued billing expectation is for claims with a primary insurance payment to indicate the Other Coverage Code value of 2, the amount the primary insurance paid is entered in the Other Payer Amount Paid field, and the same amounts billed to the primary insurance are entered in the Gross Amount Due and Usual & Customary fields. Inability to Pay Copay Kansas Legislature provided limited funds to assist with eligible Medicare Part D copays. Since this assistance is funded through All State Funds, providers may refuse service when a beneficiary cannot pay any leftover Medicare Part D copay after KMAP has applied the maximum allowed for Medicare Part D copay per your provider agreement. BILLING INSTRUCTIONS 7-7

11 7010. Updated 04/08 Notes: This rule applies only when KMAP assists with Medicare Part D copay. Providers cannot refuse service for a beneficiary s inability to pay his or her copay for all other KMAP paid services. Refer to the General Third Party Payments Provider Manual, Section 3000, for more information. The copay indicator, located on the beneficiary s ID card, identifies whether the beneficiary is responsible for a Medicaid copay. If the indicator is N, the beneficiary does not have a Medicaid copay. If the indicator is Y, the beneficiary has a Medicaid copay. Long Term Care Returned Medication Process Due to concerns raised with misapplication of the National Council for Prescription Drug Program s (NCPDP s) Version 5.1 Quantity Dispensed (442-E7) and Days Supply (405-D5) fields, please note the changes below in the process to receive incentive payments for returned medications for beneficiaries residing in long term care facilities. Beginning November 1, 2005, KMAP recommends processing an adjustment as the first step of the incentive fee process (as opposed to a POS reversal). This is particularly important if your POS software does not allow for appropriate tracking of reversed or resubmitted claims in returned medication situations. 1. Process an adjustment for the original paid claim and original prescription number. The adjusted claim is to reflect the quantity of drug used. See Section 5600 in the General Billing Provider Manual for procedures to submit an adjustment. Submit completed adjustment request forms to KMAP via mail, KMAP Web site, or fax ( ). For information on how to submit an adjustment on the KMAP secured Web site, contact the Customer Service Center at , option Document the following information and submit to the address below: a. Date of original service (dispense date), original prescription number, and original claim internal control number (ICN) b. Date adjustment was submitted to KMAP c. Dollar amount of unused medication, called credited prescription amount (CPA) To calculate the CPA, subtract the dispensing fee ($3.40) from the original payment. Divide that amount by the number of units (tabs/caps) originally dispensed, resulting in the paid amount per unit. Multiply the paid amount per unit by the number of unused tabs/caps that were returned, resulting in the CPA. KMAP uses the CPA to calculate the incentive fee, based on the table below. If the CPA is less than $5.00, no incentive fee is paid. Credited Prescription Amount Incentive Fee $0.01 to $ $0.00 $5.00 to $ $1.70 $8.26 to $11.50.$2.50 $11.51 to $ $3.25 $14.76 to $ $4.00 $18.00 and over $4.50 BILLING INSTRUCTIONS 7-8

12 7010. Updated 04/08 Submit the required information to: Kansas Medical Assistance Program Attn: Pharmacy LTC Returned Medications PO Box 3571 Topeka, KS Submission of Prescribing Provider Identifier As of April 1, 2008, pharmacy providers must submit all electronic claims with the prescribing provider s unique NPI. Paper claims must be submitted with the prescribing provider s NPI or KMAP provider ID. The following information is required for KMAP pharmacy claims: POS: Submit the NPI qualifier (01) in the Prescriber ID Qualifier field (466-EZ). Submit the prescriber s NPI in the Prescriber ID field (411-DB). Internet: Submit the prescriber s NPI in the Prescriber NPI field. Provider Electronic Solutions (PES): Submit the prescriber s NPI in the Prescriber NPI field. Paper: Submit the prescribing provider s NPI or KMAP provider ID in the Prescribing Physician Medicaid Number field (field 8). Pharmacy providers can search for a prescribing provider s NPI using the secured KMAP Web site. Only the NPIs for KMAP-enrolled prescribing providers who have shared their NPI with KMAP are available. This feature is available to users associated with a provider ID enrolled as a pharmacy provider type. To search for a prescribing provider s NPI, follow the steps below: 1. Log on to the secured KMAP Web site. 2. Click Prescribing NPI Search. 3. Select the prescribing provider type (physician, advance practice nurse, dentist, mid-level practitioner, optometrist, or podiatrist). Note: The search can be narrowed by entering the provider s last name or beginning characters of the last name, city, or ZIP code. The county and state can also be selected from drop-down lists. 4. Click Search to display the results. The prescribing providers name, phone number, and NPI are included in the results. ProDUR Alerts and Submission of NPIs on Point-Of-Sale Claims Previously, prescribing providers may have been identified by the DEA number or KMAP provider ID. As of April 1, 2008, they must be identified by the NPI on all electronic claims. Prior to May 23, 2008, pharmacy providers may have been identified by KMAP provider ID. As of May 23, 2008, pharmacy providers must be identified by the NPI on all electronic claims. For a short period of time, pharmacy providers may receive the ProDUR Response 3 - Other Pharmacy in the Other Pharmacy Indicator field (529-FT), even if the involved claims were submitted by the same pharmacy. This is because it appears the claims were submitted by two different pharmacy providers since each claim contained a different pharmacy identification number. BILLING INSTRUCTIONS 7-9

13 7010. Updated 04/08 Pharmacy providers may also receive the ProDUR Response 2 - Other Prescriber in the Other Prescriber Indicator field (529-FX), even if both prescriptions were written by the same prescribing provider. This is because it appears each claim contained a different prescribing provider identification number. Please contact the KMAP Customer Service Center if clarification is needed for claims that are returned with questionable ProDUR responses. BILLING INSTRUCTIONS 7-10

14 BENEFITS AND LIMITATIONS Updated 04/08 Copayment There will be a $3 charge per new or refilled prescription per date filled. Refer to Section 3000 of the General TPL Provider Manual for exceptions. Note: Only one $3 copayment charge will be assessed per compound prescription (even though one compound may be made up of multiple single claims.) Do not reduce charges or balance due by copayment amount. This reduction will be made automatically by EDS. Note: For beneficiary copayments related to eligible Medicare Part D copay assistance claims, please refer to Section

15 BENEFITS AND LIMITATIONS Updated 08/08 Benefit Plan Pharmaceutical benefits for MediKan beneficiaries are limited to prescription drugs that have been approved for MediKan coverage. To determine MediKan coverage for a national drug code (NDC), providers can access the following resources: Kansas Medical Assistance Program (KMAP) Web site Providers can access the KMAP Web site at NDC coverage can be verified under the Provider menu item by choosing Reference Codes then NDC Search. To conduct a search without logging into the secure site, select MediKan from the list of benefit plans in order to search for applicable MediKan coverage. Automated Voice Response System (AVRS) AVRS can be accessed at Providers press 1 followed by 1 and then the # key to log in to AVRS. After entering the KMAP provider ID or NPI, enter the four-digit PIN. If assistance is needed with the PIN number, contact KMAP Customer Service. After logging into voice response, choose option 3 from the main menu to conduct an NDC coverage search. Refer to Section 2000 of the General Benefits Provider Manual for information on the plastic State of Kansas Medical Card and eligibility verification. For further questions, contact KMAP Customer Service at or

16 BENEFITS AND LIMITATIONS 8400 Updated 3/04 Medicaid Due to the Omnibus Budget Reconciliation Act (OBRA) of 1990, the Kansas Medicaid Pharmacy Program covers all prescription drugs which are included in the Master Contract Agreement between the Centers for Medicare and Medicaid Services (CMS) and the manufacturer, with the exception of exclusions listed in this section. All drugs must be prescribed by licensed practitioners and dispensed by licensed pharmacies, approved dispensing physicians, or approved hospitals. All claims for covered drugs (including refills) must be substantiated by a prescription from a licensed practitioner. The prescription must be on file at the dispensing pharmacy. Counseling Requirements: Kansas Medical Assistance Program pharmacy providers will provide prescription drug counseling [as is currently required under Kansas Administrative Regulation (e)]. Standards and criteria to be used for counseling will be as stated in the United States Pharmacopoeia Drug Information (USP DI), the American Medical Association Drug Evaluations (AMA DE), and the American Hospital Formulary Service Drug Information (AHFS DI), and such standards and criteria as are subsequently adopted by the Health Care Policy Division. Before each prescription is dispensed or delivered, the pharmacist must offer (and document the refusal or actual counseling subsequent to such offer) to discuss with each Kansas Medical Assistance Program consumer or caregiver of such individual (in person, whenever practicable, or through access to a telephone service which is toll-free for long-distance calls) who presents a prescription, matters which, in the exercise of the pharmacist's professional judgment, the pharmacist deems significant including the following: (a) The name and description of the medication. (b) The dosage form, dosage, route of administration, and duration of drug therapy. (c) Special directions and precautions for preparation, administration and use by the patient. (d) Common severe side or adverse effects or interactions and therapeutic contraindications that may be encountered, including their avoidance, and the action required if they occur. (e) Techniques for self-monitoring drug therapy. (f) Proper storage. (g) Prescription refill information. (h) Action to be taken in the event of a missed dose. 8-3

17 8400. Updated 04/08 A reasonable effort must be made by the pharmacist to obtain, record, and maintain at least the following "patient profile" information regarding Kansas Medical Assistance Program consumers: (a) (b) (c) Name, address, telephone number, date of birth (or age) and gender. Individual history where significant, including disease state or states, known allergies and drug reactions, and a comprehensive list of medications and relevant devices. Pharmacist comments relevant to the individual's drug therapy. Documentation of actual counseling performed may be by check-off box, on the profile, or recorded elsewhere, but must be readily retrievable for each prescription filled or refilled. Verification of individual pharmacy policies and procedures, as well as documentation of actual counseling information may be requested either by on-site personnel or by request to submit copies. On-site personnel may also conduct "face-to-face" counseling as appropriate. Nothing in this policy shall be construed as requiring a pharmacist to provide consultation when a consumer or caregiver of such individual refuses such consultation; however, such refusal shall be documented. The verbal offer to counsel for each prescription medication order, the collection of patient data for the Patient Profile, and the documentation of counseling done or refused, may be delegated by the pharmacist to competent supportive/technical personnel working under a pharmacist's direct supervision. The verbal counseling, however, must be performed by a registered pharmacist. Written consultation material may be provided in addition to the verbal counseling. An exception is allowed for drugs dispensed to residents of nursing facilities which are in compliance with the drug regimen review procedures for such facilities. Therefore, the verbal counseling requirements for the dispensing pharmacist are optional for medications dispensed and delivered to nursing facilities for their residents. Dispensing Fee: The following table summarizes the professional pharmacy fee (dispensing fee) history. The professional fee listed is per claim based upon dates of service. Professional Fee Dates of Service $3.40 Effective July 1, 2002 $4.50 Effective August 1, 2000 Provider Specific Prior to August 1, 2000 Note: The above dispensing fee information is not applicable to Medicare Part D copay assistance claims. Refer to Section 7010 for these claims. 8-4

18 8400. Updated 07/08 Immunization Administration by Certified Pharmacists Pharmacy providers certified to administer vaccine to adults, in accordance with K.S.A , will be allowed to bill Medicaid for vaccine administration. Certified pharmacists are required to submit proof of certification required by K.S.A to the Medicaid provider enrollment unit in order to be eligible for vaccine administration reimbursement. Pharmacists will receive a new specialty which will allow these services to be billed to Medicaid using the provider s durable medical equipment (DME) number. Refer to Section 7020 of the DME Provider Manual for a list of procedure codes that are covered. The procedure codes must be filed on a CMS-1500 claim form using the provider s DME number. Indian Health Services Enrolled as Pharmacy Providers Indian Health Services (IHS) and Tribal 638 facilities may now enroll as pharmacy providers with KMAP. These type of facilities are not required to obtain a Kansas pharmacy license, but they must meet all applicable standards for licensure. The pharmacist for the facility must have an active pharmacy license, not necessarily from the State of Kansas. Nondrug Items Per the Centers for Medicare & Medicaid Services (CMS) any nondrug items as defined by FDA are noncovered under the pharmacy program. These items include medical supplies (such as sodium chloride and water for inhalation) and over-the-counter nutritional supplements, such as calcium supplements, vitamins and minerals. These items will also be noncovered for KAN Be Healthy (KBH) participants. Out-Of-State/Mail Order Pharmacy Providers Out-of-state/mail order pharmacy providers are permitted limited participation in KMAP. Mail order pharmacy claims which have been reimbursed in part by a third-party payer may be submitted to Medicaid for consideration of coinsurance and deductible when the drug is currently covered through the Kansas Medicaid Pharmacy Program. Reimbursement will not be considered on these claims unless payment has been made by a third-party payer. Over-the-Counter Items Many drugs that do not by law require a prescription are covered when prescribed by a licensed prescriber. Over-the-counter pharmacy products are reviewed on a postpayment basis and included as a component of on-site pharmacy reviews. The following therapeutic classes of drugs are covered for KBH participants: Antihistamine combinations Antipyretics Decongestants Cough and cold products 8-5

19 8400. Updated 04/08 Pharmacy Pricing: Pharmaceutical items covered by the program are reimbursed at the lesser of the provider's Usual and Customary (U&C) or Gross Amount Due (GAD) amount or the state's reimbursement methodology plus a professional fee. Exceptions to the usual pricing methods apply to certain designated products. The state maximum allowable cost (SMAC) and the estimated acquisition cost (EAC) are predetermined by the state for each covered drug. The EAC reimbursement methodology will be based on Average Wholesale Price (AWP) minus a percent based on the date of service on the claim. The following chart lists the EAC reimbursement history for most NDCs. Effective 2/18/2003 AWP -13% AWP - 27% Effective 10/1/2002 AWP - 11% AWP - 27% Prior to 10/1/2002 AWP - 10% The allowable amount for anti-hemophilic products is the lesser of Kansas Department of Health and Environment (KDHE) Contract Pricing (if applicable) or AWP minus 30%. A State-assigned SMAC price may be applicable if KDHE contract pricing is not available or in response to market price changes. The allowable amount for all sterile irrigation solutions, large volume parenteral (LVP), and small volume parenteral (SVP) fluid replacements for intravenous drug administration are reimbursed at AWP minus 50%. Maximum reimbursement rates designated as Maximum Allowable Costs (MAC), formerly known as Federal Upper Limits (FUL) continue to be established by the Centers for Medicare & Medicaid Services (CMS) for various multi-source products. To ascertain current allowable amounts, providers can use the Automated Voice Response System at , transaction code 6. View updated federal and state pricing information using the National Drug Code (NDC) search feature on the KMAP Web site. From the KMAP Web site home page ( point to Provider, Reference Codes, and then click NDC search or go directly to: Note: The above pharmacy pricing information is not applicable to Medicare Part D copay assistance claims. Refer to Section 7010 for these claims. Preferred Drug Listing: The 2002 Legislature passed a law (2002 Session Laws of Kansas, Chapter 180 Kan. Sess. L., 200, c.180) permitting Kansas Medicaid to implement a Preferred Drug List (PDL). The Medicaid agency Department convened an advisory committee of practicing physicians and pharmacists to evaluate drugs in therapeutic drug classes for clinical equivalence and to make recommendations to the agency Kansas Department of Social and Rehabilitation Services (SRS) and to the Drug Utilization Review Board (DUR). Using a PDL will promote clinically appropriate use of drugs in a cost-effective manner. 8-6

20 8400. Updated 09/08 After the PDL Advisory Committee and DUR Board recommendations, and as published in the Kansas Register, new prescriptions for the nonpreferred drugs will require prior authorization. The PDL KMAP Coverage List(s) and the Prior Authorization Request forms can be found via the website at: As other therapeutic drug classes are evaluated by the PDL Advisory Committee and the DUR Board, KMAP will publish this information to providers. Prior Authorization Prior authorization forms (non-pdl drugs) that require prior authorization are available at: Forms.html Prescription Filing Requirement All prescriptions dispensed must be filed in accordance with regulations of the Board of Pharmacy. The records must be kept in such a manner as to allow reasonable ease of audit by agents of KHPA, appropriate agents of the federal government, or authorized agents of utilization review committees operating under the authority of either state or federal agencies. This requirement applies with equal force to all providers of pharmaceutical services. Tamper-Resistant Prescriptions All written, nonelectronic prescriptions for outpatient drugs for KMAP beneficiaries must be written on tamper-resistant pads or paper, as required in Section 1903(i)(23) of the Social Security Act; 42 U.S.C. Sec. 1396b(i)(23). CMS Requirements of a Tamper-Resistant Prescription Pad or Paper Effective on and after October 1, 2008, written prescriptions for KMAP beneficiaries must have all three of the following requirements to be considered tamper-resistant. 1. One or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form 2. One or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber 3. One or more industry-recognized features designed to prevent the use of counterfeit prescription forms Prescriptions exempt from the tamper-resistant requirements include the following: Electronic, faxed, or verbal prescriptions Prescriptions covered by a managed care entity Medications dispensed directly to patients by the prescribing provider In most situations when drugs are provided in certain institutional and clinical facilities 8-7

21 8400. Updated 09/08 Clarification for Specific Situations Emergency Filling A pharmacy may fill a prescription on an emergency basis and dispense the full prescription to the patient only if the pharmacy obtains a compliant prescription in writing or via telephone, fax, or e-prescription within 72 hours. Institutional Setting A prescription is considered tamper-resistant when a written order is prepared in an institutional setting, and all of the three following requirements have been met: The doctor or medical assistant writes the order into the medical record. The order is given by medical staff directly to the pharmacy. The patient never has the opportunity to handle the written order. Controlled Substances Federal and Kansas laws require all Schedule II controlled substance prescriptions to be written. If a nontamper resistant Schedule II controlled substance prescription is presented to a pharmacy and is compliant with federal and Kansas laws, then the prescription can be considered tamper-resistant through telephone, fax, or e-prescription verification. Prescription Transfer When a prescription for a KMAP beneficiary is transferred from one pharmacy to another, the pharmacy receiving the prescription must verify with the original pharmacy that the prescription met the tamper-resistant requirements. This verification can be done by telephone or fax. The receiving pharmacy does not need to obtain direct confirmation from the prescribing provider. Compliance The primary responsibility for auditing KMAP providers rests with KHPA. However, there are some circumstances in which CMS, the Office of the Inspector General of the U.S. Department of Health and Human Services, or some other federal agency may have occasion to audit a pharmacy provider. When this occurs, the federal agency will have the authority to determine compliance with the tamper-resistant requirements. Retroactive Eligibility When a KMAP beneficiary is retroactively eligible, the previously filled prescriptions will be considered tamper-resistant. Any future original or refill prescriptions must be tamper-resistant. Refills on Prescriptions Dated Prior to April 1, 2008 If the original prescription was dated and presented to the pharmacy prior to April 1, 2008, then the prescription and its refills do not have to be tamper-resistant. Refills A refill may only be provided when specifically ordered by the practitioner.a prescription may be refilled in accordance with applicable federal and state laws up to one year from date of issue for non-controlled drugs, after which time a new prescription must be obtained. Refills on controlled substances are limited by applicable federal and state law. The refill date and the initials of the dispensing pharmacist must be recorded on the patient record or on the front or back of the prescription for all refills. 8-8

22 8400. Updated 09/08 Telephone Prescriptions Telephoned prescriptions, when allowed by applicable federal and state laws and promptly reduced to writing, are acceptable; however, the signature/initials of the pharmacist receiving the prescription must be indicated on the prescription. Drug Benefit Limitations Amphetamines, Amphetamine mixtures and Amphetamine-Like Drugs: Amphetamines, amphetamine mixtures and amphetamine-like drugs require an ICD-9 diagnosis code to be entered on the claim. Applicable diagnoses are: ADD ADHD Cataplexy and Narcolepsy 347 Note: KMAP does not cover amphetamines, amphetamine mixtures and amphetamine-like drugs when used to treat diagnoses other than the above mentioned. Antitubercular Antibiotics Antitubercular drugs are noncovered. They are covered free of charge through local health departments. Use of antitubercular drugs for conditions other than tuberculosis requires prior authorization. Benzodiazepines (with dates of service on and after January 7, 2005) The daily limits on benzodiazepines are as follows: Alprazolam (Xanax ) 120 mg/30 days Diazepam (Valium ) 1200 mg/30 days Clorazepate (Tranxene ) 2700 mg/30 days Temazepam (Restoril ) 900 mg/30 days Lorazepam (Ativan ) 180 mg/30 days Note: Xanax XR (alprazolam), Tranxene SD (clorazepate) and Niravam (alprazolam) are excluded from benzodiazepine coverage. Coverage of new benzodiazepine products will be determined by KMAP. Buprenorphine/Naloxone (Suboxone) and Buprenorphine (Subutex) Effective with dates of service on and after March 1, 2007, Buprenorphine/Naloxone (Suboxone ) and Buprenorphine (Subutex ) require prior authorization. Daily dosing is not to exceed 40 mg per day. Butorphanol Butorphanol claims in excess of 12.5 units per calendar month will be denied. (One spray pump equals 2.5 cc or 2.5 billing units). Emergency Rx Dispensing When a prescription is dispensed that requires prior authorization (PA) in an emergency situation or after regular PA office hours, the pharmacy should call the PA unit and leave a message on the answering machine indicating date, time, beneficiary ID and the medication being dispensed. This will be taken as intent to begin the PA process. Only a quantity that will provide treatment to the beneficiary until the next business day should be dispensed until PA can be secured. The PA unit will return the telephone message the 8-9

23 8400. Updated 09/08 next working day and process a PA if medical criteria are met. The remainder of the prescription can be dispensed at that time. If PA is denied, only the portion of the medication dispensed emergently during non-working hours/days will be reimbursed. Fentanyl Citrate Transmucosal Systems (Actiq) Prior authorization is required for Actiq. PA criteria include the following: Beneficiary must be 16 years of age or older. Quantity limit must be four units (lozenges) per day. Prescriber must be an oncologist or pain specialist. Beneficiary must have a diagnosis of malignant cancer. Beneficiary must be receiving opioid therapy and be considered opioid tolerant. Gabapentin (Neurontin) An ICD-9-CM diagnosis code is required on all gabapentin claims. The pharmacy will need to contact the prescribing provider if no diagnosis is noted on the prescription. Gabapentin is only covered for the following conditions or diagnoses listed below: 1. Neuropathic pain: for a diagnosis indicating neuropathic pain, submit diagnosis code Epilepsy: for a diagnosis of epilepsy, submit the most appropriate one of the following diagnosis codes (KMAP will accept for epilepsy diagnoses within the range of to ) a generalized nonconvulsive epilepsy without mention of intractable epilepsy b generalized nonconvulsive epilepsy with intractable epilepsy c generalized convulsive epilepsy without mention of intractable epilepsy d generalized convulsive epilepsy with intractable epilepsy e generalized convulsive epilepsy, petit mal status f generalized convulsive epilepsy, grand mal status g partial epilepsy, with impairment of consciousness without mention of intractable epilepsy h partial epilepsy, with impairment of consciousness with intractable epilepsy i partial epilepsy, without mention of impairment of consciousness without mention of intractable epilepsy j partial epilepsy, without mention of impairment of consciousness with intractable epilepsy k infantile spasms without mention of intractable epilepsy l epilepsia partialis continua without mention of intractable epilepsy m epilepsia partialis continua with intractable epilepsy n other forms of epilepsy without mention of intractable epilepsy o other forms of epilepsy with intractable epilepsy p epilepsy, unspecified without mention of intractable epilepsy q epilepsy, unspecified with intractable epilepsy r other convulsions s epilepsy due to late effects of intracranial injury 8-10

24 8400. Updated 08/07 Influenza Treatment: Prescription drug claims for neuraminidase inhibitors zanamivir (Relenza ) and oseltamivir (Tamiflu ) will be paid for dates of service during the influenza (flu) season only (October 1 through April 30) and will be limited to one course of therapy per beneficiary per flu season. According to the Kansas Department of Health and Environment, the Centers for Disease Control consider the flu season in Kansas to be from mid-october through mid-april. One course of therapy for both Relenza and Tamiflu are defined by the company in the package insert as five days of therapy. Ketorolac (Toradol ) Claims submitted for greater than a five day supply will be denied. Long-Term Care Units (LTCU): Hospitals approved by SRS with long-term care units may bill for covered drugs dispensed for use by Medicaid beneficiaries. The following guidelines apply only to LTCUs, where automatic stop orders in the acute care area might result in an unreasonable number of billings for drugs used on a continuing basis by LTCU residents. Therapeutic Class Antibiotics Anticoagulants Narcotics, Stimulants, and Depressants Steroids Other drugs given on an irregular or PRN basis Drugs given on a continuing maintenance schedule Injectable drugs normally supplied in single dose ampules Injectable drugs normally supplied in multiple dose vials Days Supply Payable 7 days 7 days 7 days 7 days 30 days 31 days 7 days vial size When the quantity of medication ordered by the physician conflicts with the hospital's policy regarding automatic stop orders or maximum dispensing quantities, the days supply guidelines as described above should be used for billing. Medication used on a continuing or permanent basis should be billed for a 31 day supply. When a physician orders a short course of drug therapy, the quantity of medication should be billed on a single claim form. Billing for medication for LTCU patients must be done: 1) monthly, or 2) upon discharge of the patient (using the date medication was dispensed rather than date of administration). 8-11

25 8400. Updated 10/07 Maintenance Drug Allowable Criteria: Covered drugs designated as maintenance drugs by KMAP must be dispensed in a 31- day supply if the physician s order is written for a 31-day supply or greater. This criteria is for all pharmacy providers, including Adult Care Home providers. An override is allowed if the beneficiary meets one of the following criteria: A single unit dispensed, such as DepoProvera 150 mg, for contraceptive purposes, exceeds a 31-day supply A child's school requires a separate medication supply Primary insurance requires more than a 31-day supply, AND primary made a payment. (If primary payment is identified on the claim, the system will automatically override.). The allowable override is a value of "02" (other override) in the NCPDP submission clarification override code field. For web claims, the allowable override is the text option Other Override in the Submission Clarification Code field. Providers utilizing the override code must keep written documentation of the reason for use. Unauthorized reduction of prescription quantities is considered prescription splitting and is not allowed. Schedule II, III, IV, and V drugs are exempt from minimum quantity limitation requirements, but should be prescribed and dispensed in reasonable quantities. Maximum Allowable Quantities: No more than a 31-day supply of medication per prescription may be dispensed at one time. Modafinil (Provigil): Modafinil (Provigil ) is covered for the following diagnoses and ICD-9 codes: Cataplexy and Narcolepsy 347 Obstructive Sleep Apnea/Hypopnea Shift Work Sleep Disorder Note: KMAP does not cover modafinil (Provigil) when used to treat diagnoses other than the above mentioned. Nabilone (Cesamet): Nabilone (Cesamet ) requires PA. Dosing is limited to no more than 30 capsules or tablets per claim. PA does not override this quantity restriction. 8-12

26 8400 Updated 10/05 Narcotic Analgesics, Tramadol, and Skeletal Muscle Relaxants: Medicaid will not reimburse drug claims that exceed maximum recommended dosing during any thirty-day period for scheduled narcotic analgesics, narcotic analgesic combination products, tramadol, and skeletal muscle relaxants. For medically necessary conditions which require more than the maximum approved dosage, the dose may be approved through the prior authorization process. The claim must be supported with documentation in the consumer's medical records. Medications included are: Acetaminophen, Aspirin, or Ibuprofen combination products containing any of the following: Butalbital, Codeine, Dihydrocodone, Hydrocodone, Oxycodone, Pentazocine, Propoxyphene, or Tramadol (also included are single ingredient narcotic analgesic, and skeletal muscle relaxant products) Carisoprodol (Soma ), Cyclobenzaprine (Flexeril ), Metaxalone (Skelaxin ), Methocarbamol (Robaxin ), Orphenadrine (Norflex ), Tizanidine (Zanaflex ) Hydromorphone (Dilaudid ) Meperidine (Demerol ) Narcotic Agonist/Antagonist combinations of Pentazocine (Talwin NX, Talwin Compound, Talacen ) Tramadol (Ultram ) Oxycodone (Oxycontin ) Nursing Services Requirements for IV Medication/Nutrition: Pharmacy services provided for parenteral administration of total nutritional replacements and intravenous medication in the consumer's home require that nursing services from a local home health agency be provided. Areas not serviced by a home health agency may utilize the local health department or an advanced registered nurse practitioner. Postpayment reviews of pharmacy provider charges and reimbursement include verification that required nursing services were provided. OxyContin: Per the package insert, OxyContin (oxycodone 12 hour sustained release) dosing frequency is every 12 hours for symmetrical dosing (same morning and evening times) or twice a day for asymmetrical dosing (different morning and evening times). KMAP allows a dosing schedule of every 12 hours, symmetric or asymmetric, for all strengths of OxyContin (oxycodone 12 hour sustained release). KMAP will not deny claims based on the OxyContin (oxycodone 12 hour sustained release) dosing schedule but may recoup claims dispensed for other dosing schedules, such as every eight hours. Parenteral & Irrigation Solution Reimbursement: All sterile irrigation solutions, large volume parenteral, and small volume parenteral (SVP) fluid replacements for intravenous drug administration are reimbursed the Average Wholesale Price (AWP) less 50%. 8-13