Prescription Drug Program Billing Guide
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Washington Apple Health (Medicaid) Prescription Drug Program Billing Guide July 1, 2020 Disclaimer Every effort has been made to ensure this guide’s accuracy. If an actual or apparent conflict between this document and Health Care Authority (HCA) rule arises, HCA rules apply. Billing guides are updated on a regular basis. Due to the nature of content change on the internet, we do not fix broken links in past guides. If you find a broken link, please check the most recent version of the guide. If this is the most recent guide, please notify us at [email protected]. About this guide* This publication takes effect July 1, 2020, and supersedes earlier billing guides to this program. The Health Care Authority is committed to providing equal access to our services. If you need an accommodation or require documents in another format, please call 1-800-562-3022. People who have hearing or speech disabilities, please call 711 for relay services. Washington Apple Health means the public health insurance programs for eligible Washington residents. Washington Apple Health is the name used in Washington State for Medicaid, the children’s health insurance program (CHIP), and state-only funded health care programs. Washington Apple Health is administered by the Washington State Health Care Authority. Refer also to HCA’s ProviderOne billing and resource guide for valuable information to help you conduct business with the Health Care Authority. How can I get HCA Apple Health provider documents? To access provider alerts, go to HCA’s provider alerts webpage. To access provider documents, go to HCA’s provider billing guides and fee schedules webpage. Where can I download HCA forms? To download an HCA form, see HCA’s Forms & Publications webpage. Type only the form number into the Search box (Example: 13-835). * This publication is a billing instruction. CPT® codes and descriptions only are copyright 2019 American Medical Association. 2 | PRESCRIPTION DRUG PROGRAM BILLING GUIDE Copyright disclosure Current Procedural Terminology (CPT) copyright 2019 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. What has changed? Subject Change Reason for Change Entire guide Revised format of entire To comply with accessibility standards guide Removed Apple Health Program update. The Apple Health Medicaid Fee-For-Service (Medicaid) Fee-For-Service Preferred Preferred Drug List and Drug List no longer applies. All PDL replaced with Apple Health products are listed on HCA’s Apple Preferred Drug List. Health Preferred Drug List which is used by managed care plans and the fee-for-service program. What drugs, devices, and Removed the Apple Health Covered over the counter products are supplies are covered Fee-For-Service Covered now listed on HCA’s Apple Health Over the Counter Drug List Preferred Drug List What drugs, devices, and Removed the Apple Health Covered over the counter products are supplies are not covered Fee-For-Service Covered now listed on HCA’s Apple Health Over the Counter Drug List Preferred Drug List Cough and cold drug Removed the Apple Health Covered cough and cold products are coverage Fee-For-Service Covered listed on HCA’s Apple Health Cough and Cold Drug List Preferred Drug List. Authorization for proton Removed ranitidine 400 mg FDA recommended removal of pump inhibitors (PPIs) daily. ranitidine from the market due to safety concerns. Does the agency cover Removed the Apple Health Covered over the counter products are over-the-counter (OTC) Fee-For-Service Covered now listed on HCA’s Apple Health drugs Over the Counter Drug List Preferred Drug List. CPT® codes and descriptions only are copyright 2019 American Medical Association. 3 | PRESCRIPTION DRUG PROGRAM BILLING GUIDE Subject Change Reason for Change What do the POS Removed the word denial Stating “denial” is not accurate as a rejection codes mean and replaced with claim claim rejection through the POS rejections. system is not necessarily a denial of service. Program Update. The Apple Health Removed Apple Health (Medicaid) Fee-For-Service Preferred Fee-For-Service Preferred Drug List no longer applies. All PDL Drug List and replaced with products are listed on HCA’s Apple Apple Health Preferred Health Preferred Drug List which is Drug List used by managed care plans and the fee-for-service program. What drugs may be Removed “formerly known Program update. prescribed for Family as TAKE CHARGE” Planning Only Program Apple Health Preferred Title changed from Apple Program update. Drug List Health Medicaid: Fee-For- Service Preferred Drug List. What are the Added statement that Clarification. authorization criteria to pharmaceutical samples obtain a nonpreferred given to the client do not drug apply toward the number of preferred drugs tried. CPT® codes and descriptions only are copyright 2019 American Medical Association. 4 | PRESCRIPTION DRUG PROGRAM BILLING GUIDE Table of Contents Resources Available ......................................................................................................................... 10 Troubleshooting ................................................................................................................................ 12 Definitions ............................................................................................................................................ 14 About the Program .......................................................................................................................... 20 What is the purpose of the Prescription Drug Program? ......................................... 20 What are the provider requirements? ................................................................................ 21 Abuse of the program................................................................................................................ 21 Client Eligibility .................................................................................................................................. 22 How do I verify a client’s eligibility? ................................................................................... 22 Verifying eligibility is a two-step process: .................................................................. 22 What types of identification prove eligibility?............................................................... 23 What if a claim is denied by the point-of-sale (POS) system? ............................... 23 Are clients enrolled in an agency-contracted managed care organization (MCO) eligible? .............................................................................................................................. 24 Managed care enrollment ................................................................................................... 24 Apple Health – Changes for January 1, 2020 ............................................................. 25 Clients who are not enrolled in an HCA-contracted managed care plan for physical health services ........................................................................................................ 26 Integrated managed care .................................................................................................... 26 Integrated managed care regions ................................................................................... 26 Integrated Apple Health Foster Care (AHFC) ............................................................ 27 Fee-for-service Apple Health Foster Care ................................................................... 28 Program Restrictions ....................................................................................................................... 29 How does HCA determine which drugs to cover? ....................................................... 29 What drugs, devices, and supplies are covered? .......................................................... 29 What drugs, devices, and supplies are not covered? ................................................. 30 What are the exceptions to the prescription requirement? .................................... 33 Compliance Packaging ................................................................................................................... 34 What is included in compliance packaging?................................................................... 34 How is it determined that a client is eligible for compliance packaging? ....... 34 What is required when billing for compliance packaging? ..................................... 35 Billing for single-dose vials ..................................................................................................... 36 Does a provider need agency approval to bill for splitting single-dose vials?............................................................................................................................................... 36 Compounded Prescriptions ......................................................................................................... 38 What is compounding? ............................................................................................................. 38 CPT®