Prescription manual

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Your selected treatments will be delivered for free in discreet packaging. Chat with a medical expert whenever you need. On the phone or via email. With support throughout your treatment. The most effective treatments. Backed by science. In addition to stating whether the PAR has been approved or denied, a PAR denial notification letter is sent to members. This letter identifies the member's appeal rights.

Only members have the right to appeal a PAR decision. If additional information is requested in order to process the PAR, the physician should provide the information by phone or fax. Approval of a PAR does not guarantee payment. PARs only assure that the approved service is medically necessary and considered to be a benefit of the Health First Colorado program.

All claims, including those for prior authorized services, must meet claim submission requirements before payment can be made. Some claim submission requirements include timely filing, eligibility requirements, pursuit of third-party resources, and required attachments included.

A PAR approval does not override any of the claim submission requirements. In determining what drugs should be subject to prior authorization, the following criteria is used:. Most brand-name drugs with a generic therapeutic equivalent are not covered by the Health First Colorado program.

For DEA Schedule 2 through 5 drugs, 85 percent of the days' supply of the last fill must lapse before a drug can be filled again. For non-scheduled drugs, 75 percent of the days' supply of the last fill must lapse before a drug can be filled again.

If the appropriate numbers of days have not lapsed, the claim will be denied as a refill-too-soon unless there has been a change in the dosing. For non-mail order transactions, there is a maximum day accumulation allowed every rolling days. If a Medicaid member enters or leaves a nursing facility, the member may require a refill-too-soon override in order to receive his or her drugs. All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions.

This requirement stems from the Social Security Act, 42 U. Prescriptions must be written on tamper-resistant prescription pads that meet all three of the stated characteristics. A compounded prescription a prescription where two or more ingredients are combined to achieve a desired therapeutic effect must be submitted on the same claim.

A PAR is only necessary if an ingredient in the compound is subject to prior authorization. Pharmacies may use the number 8 in Field DK instead of obtaining a PA for non-covered ingredients to allow the claim to pay for the ingredients that are considered a covered benefit. The Health First Colorado program does not pay a compounding fee. Prescriptions generally cannot be dispensed in quantities less than the physician ordered unless the quantity ordered is more than a day supply for maintenance medications or more than a day supply for non-maintenance medications.

Please Note: Incremental and subsequent fills are not permitted for compounded prescriptions. Incremental and subsequent fills may not be transferred from one pharmacy to another.

The standard drug ingredient reimbursement methodology applies to the quantity dispensed with each fill. Incremental and subsequent fills must be dispensed within 60 days of the prescribed date. Please note: if a pharmacy submits a claim for a non-Schedule II medication and includes a value for quantity prescribed, it must be a valid value.

Submitting a quantity dispensed greater than quantity prescribed will result in a denied claim. In an emergency, when a PAR cannot be obtained in time to fill the prescription, pharmacies may dispense a hour supply 3 days of covered outpatient prescription drugs to an eligible member by calling the Pharmacy Support Center. An emergency is any condition that is life-threatening or requires immediate medical intervention. The Health First Colorado program will cover lost, stolen, or damaged medications once per lifetime for each member.

Pharmacies must call for overrides for lost, stolen, or damaged prescriptions. If a member calls the call center, the member will be directed to have the pharmacy call for the override.

Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. The replacement request and verification must be submitted to the Department within 60 days of the last refill of the medication.

A pharmacist or pharmacist designee shall offer counseling regarding the drug therapy to each Health First Colorado member with a new or refill prescription if the pharmacist or pharmacist designee believes that it is in the best interest of the member. The offer to counsel shall be face-to-face communication whenever practical or by telephone.

A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. The pharmacist or pharmacist designee shall keep records indicating when counseling was not or could not be provided. Applicable co-pay is automatically deducted from the provider's payment during claims processing. Providers can collect co-pay from the member at the time of service or establish other payment methods.

Services cannot be withheld if the member is unable to pay the co-pay. If the member does not pick up the prescription from the pharmacy within 14 calendar days, the prescription must be reversed on the 15th calendar day. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. Pharmacies that have an electronic tracking system shall review prescriptions in will-call status on a daily basis and enter a reversal of prescriptions not picked up within 10 days of billing.

In no case, shall prescriptions be kept in will-call status for more than 14 days. Source documents and source records used to create pharmacy claims shall be maintained in such a way that all electronic media claims can be readily associated and identified. These source documents, in addition to any work papers and records used to create electronic media claims, shall be retained by the provider for six years and shall be made readily available and produced upon request of the Secretary of the Department of Health and Human Services, the Department, and the Medicaid Fraud Control Unit and their authorized agents.

These values are for covered outpatient drugs. Enrolled Medicaid fee-for-service FFS members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies.

Local and out-of-state pharmacies may provide mail-order prescriptions for Medicaid members if they are enrolled with the Health First Colorado program and are registered and in good standing with the State Board of Pharmacy. The Health First Colorado program restricts or excludes coverage for some drug categories. More information may be obtained in Appendix P in the Billing Manuals section of the Department's website. The pharmacy benefit manager provides a Pharmacy Support Center to handle clinical, technical, and member calls.

The Pharmacy Support Center is available to answer provider claim submission and basic drug coverage questions. The Helpdesk is available 24 hours a day, seven days a week.

COVID early refill overrides are not available for mail-order pharmacies. Health First Colorado is temporarily deferring medication prior authorization PA requirements for members on all medications for which there is an existing month PA approval in place. Each PA may be extended one time for 90 days.

These will be handled on a case-by-case basis by the Pharmacy Support Center if requested by a Health First Colorado healthcare professional i. New PAs and existing PA approvals that are less than 12 months are not eligible for deferment. Pharmacists should ensure that the diagnosis is documented on the electronic or hardcopy prescription.

Note: the pharmacy may call the Pharmacy Support Center to request a zero co-pay if the medication is related to the treatment or prevention of COVID, or the treatment of a condition that may seriously complicate the treatment of COVID Please contact the Pharmacy Support Center with questions.

Pharmacies may call the Pharmacy Support Center to request a quantity limit override if the medication is related to the treatment or prevention of COVID, or the treatment of a condition that may seriously complicate the treatment of COVID Signature requirements are temporarily waived for Member Counseling and Proof of Delivery. Prescription Tracking and Claim Reversals For purposes of billing for prescribed drugs, the date of service means the date a prescription is filled.

In most circumstances, providers may not bill Montana Healthcare Programs members for services covered under Montana Healthcare Programs. More specifically, providers cannot bill members directly:. Under certain circumstances, providers may need a signed agreement in order to bill a Montana Healthcare Programs member see the following table. Custom Agreement: This agreement lists the service the member will receive and states that the service is not covered by Montana Healthcare Programs and that the member will pay for the services received.

When submitting claims for retroactively eligible members in which the date of service is more than 12 months earlier than the date the claim is submitted, attach a copy of the Provider Notice of Eligibility Form M. For more information on retroactive eligibility, see the Member Eligibility and Responsibilities chapter in the General Information for Providers manual. Providers should bill Montana Healthcare Programs their usual and customary charge for each service; that is, the same charge that is made to other payers for that service.

Effective for all claims paid on or after January 1, co-payment will not be assessed. The provider must always use the complete digit NDC from the dispensing container. The Department accepts only the NDC format. All 11 digits, including zeros, must be entered. The three segments of the NDC are:. Claims must accurately report the NDC dispensed, the number of units dispensed, days supply, and the date of dispensing.

Use of an incorrect NDC or inaccurate reporting of a drug quantity will cause the Department to report false data to drug manufacturers billed for drug rebates.

The Department will recover payments made on erroneous claims discovered during dispute resolution with drug manufacturers.

Pharmacies are required to document purchase for quantities of brands of drugs reimbursed by the Department if disputes occur. Prescribers and pharmacies must prescribe and dispense the generic form of a drug whenever possible. Except for those drugs listed below, prior authorization is required when a brand name drug is prescribed instead of a generic equivalent.

Please use the following DAW codes for these situations:. The point-of-sale POS system finalizes claims at the point of entry as either paid or denied. Pharmacies arrange their own telecommunications switch services to accept Montana Healthcare Programs point of sale and are responsible for any charges imposed by these vendors. Hard copy paper billing is still accepted when billed on a Universal Claim Form Version 1.

All claims are processed and edited through the POS system regardless of how the claim was originally submitted. If the claim continues to deny for eligibility past 3 working days, call Provider Relations at 1 Member eligibility may change monthly, so providers should verify eligibility each month. In some circumstances, the Pro-DUR edits result in denied claims. When a Pro-DUR denied claim needs to be overridden, pharmacy providers may enter one Reason for Service Code formerly DUR Conflict Code from each category in the following order, as long as the indicated situations exist and the pharmacy retains documentation in its files:.

By placing codes into the claim, the provider is certifying that the indicated DUR code is true and documentation is on file.

Instructions for completing the Universal Claim Form are described on the next below. The form is available on the Forms page of the Provider Information website. The forms below and others are available on the Forms page of the Provider Information website:. Search the whole manual. Open the Complete Manual pane.

From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word for example "Denials". The search box will show all locations where denials discussed in the manual. Search by Chapter.

Open any Chapter tab for example the "Billing Procedures" tab. The search box will show where denials discussed in just that chapter.

Site Search. Search the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page. Montana Medicaid Provider.

Prescription Drug Program Manual Printing the manual material found at this website for long-term use is not advisable. If you experience any difficulty opening a section or link from this page, please email the webmaster. How to Search this manual: This edition has three search options.

Prior manuals may be located through the provider website archives. Complete Prescription Drug Program Manual. Prescription Drug Program Manual To print this manual, right click your mouse and choose "print".

Term "Medicaid" replaced with "Montana Healthcare Programs" throughout the manual. Terms "client", "recipient" and "patient" replaced with "member". Drug Prior Authorization For all questions regarding drug prior authorization: Helena 8 a. Manual Organization This manual provides information specifically for Prescription Drug Program providers. Manual Maintenance Manuals must be kept current. Rule References Providers must be familiar with all current rules and regulations governing the Montana Healthcare Program.

Getting Questions Answered The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group such as a program officer, Provider Relations, or a prior authorization unit. Montana Healthcare Programs covers the following prescribed over-the-counter OTC products manufactured by companies who have signed a federal rebate agreement. Montana Healthcare Programs has opted to cover the following medications for all members, including Medicare Part D members: Prescription cough and cold medications OTC medications listed above.

Prescription vitamins and minerals will be granted prior authorization when indicated for the treatment of an appropriate diagnosis. The Montana Healthcare Programs Prescription Drug Program does not reimburse for the following items or services: Drugs supplied by drug manufacturers who have not entered into a federal drug rebate agreement.

Drugs prescribed: To promote fertility For erectile dysfunction For weight reduction For cosmetic purposes or hair growth For an indication that is not medically accepted as determined by the Department in consultation with federal guidelines, the DUR Board, or the Department medical and pharmacy consultants. Drugs designated as less-than-effective DESI drugs or drugs that are identical, similar, or related to such drugs.

Drugs that are experimental, investigational, or of unproven efficacy or safety. Free pharmaceutical samples. Terminated drug products.

Any drug, biological product, or insulin provided as part of, or incident to and in the same setting as, any of the following: Inpatient hospital setting Hospice services Outpatient hospital services emergency room visit Other laboratory and x-ray services Renal dialysis Incarceration Any of the following drugs: Outpatient nonprescription drugs except those OTC products previously listed Covered outpatient drugs for which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.

Medical supplies non-drug items are not covered under the Prescription Drug Program. To bill paper claims: Submit your claims on a CMS form. Mail to the Claims Processing Unit, P. Box , Helena, MT Providers using paper claims must wait 45 days after Medicare paid date to submit claims. The formulary is available on the Pharmacy page of the Provider Information website.

The Department has rebate agreements with pharmaceutical manufacturers for many of the drugs on the formulary. Providers are asked to use preferred products to the extent possible. See the Provider Information website. No more than two prescriptions of the same drug may be dispensed in a calendar month except for the following: Antibiotics Schedule II through V drugs Antineoplastic agents Compounded prescriptions Prescriptions for suicidal members or members at risk for drug abuse Topical preparations Other medications may not be dispensed in quantities greater than a day supply except where manufacturer packing cannot be reduced to a smaller quantity.

Generic Drugs The Department has a mandatory generic edit in the claims processing system. Unit Dose Prescriptions Pharmacy-packaged unit dose medications may be used to supply drugs to members in nursing facilities, group homes, and other institutional settings. Unit dose prescriptions may not exceed the day supply limit. End of Dispensing Limitations Chapter Prior Authorization Many drug products require prior authorization before the pharmacist provides them to the member.

To request prior authorization, providers must submit the information requested on the Request for Drug Prior Authorization form to the Drug Prior Authorization Unit. See the Forms link in the left menu on the Provider Information website. The prescriber e. Decisions on requests with special circumstances that require further peer review are made within 24 hours. An emergency hour supply may be dispensed for emergency, after-hours, weekend, and holiday requests.

Prior Authorization for Retroactively Eligible Members All prior authorization requirements must be met for retroactively eligible members.

When a member becomes retroactively eligible for Montana Healthcare Programs, the provider may: Accept the member as a Montana Healthcare Programs member from the current date. Accept the member as a Montana Healthcare Programs member from the date retroactive eligibility was effective.

Require the member to continue as a private-pay member. Usual and Customary The usual and customary charge is the price the provider most frequently charges the general public for the same drug.

Includes discounts advertised or given including but not limited to cash rebate, monetary price discount, coupon of value to any segment of the general public. Will use the median price if during an audit, the most frequent price cannot be determined from pharmacy records. New pharmacy providers are assigned the maximum dispensing fee. Failure to comply with the six-month dispensing fee questionnaire requirement will result in assignment of a dispensing fee of the lowest calculated cost to dispense that year.

Vaccine Administration Fee Pharmacies can receive a vaccine administration fee. The Remittance Advice The remittance advice is the best tool providers have to determine the status of a claim. Credit Balances Credit balances occur when claim adjustments reduce original payments causing the provider to owe money to the Department.

Credit balances can be resolved in two ways: By working off the credit balance. Remaining credit balances can be deducted from future claims. These claims will continue to appear on consecutive remittance advices until the credit has been paid.

This method is required for providers who no longer submit claims to Montana Healthcare Programs. Attach a note stating that the check is to pay off a credit balance and include your provider number.

Send the check to Third Party Liability. Rebilling and Adjustments Rebillings and adjustments are important steps in correcting any billing problems you may experience. Timeframe for Rebilling or Adjusting a Claim Providers may resubmit or adjust any initial claim within the timely filing limits described in the Billing Procedures chapter of this manual.

Depending on switch-vendor requirements, some point-of-sale adjustments must be completed within three months. In this case, adjustments may be submitted on paper within the timely filing limits. These time periods do not apply to overpayments that the provider must refund to the Department. After the month time period, a provider may not refund overpayments to the Department by completing a claim adjustment.

The provider may refund overpayments by issuing a check or asking the Third Party Liability Unit to complete a gross adjustment. Providers can rebill Montana Healthcare Programs when a claim is denied in full, as long as the claim was denied for reasons that can be corrected.

When the entire claim is denied, check the Explanation of Benefits EOB code, make the appropriate corrections, and resubmit the claim not an adjustment. Line Denied.