Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-9 - Pharmacy Services
Section 5160-9-02 - Pharmacy services: medical supplies and durable medical equipment
Universal Citation: OH Admin Code 5160-9-02
Current through all regulations passed and filed through September 16, 2024
(A) Eligible pharmacies in the Ohio medicaid program may bill for medical supplies and durable medical equipment in accordance with Chapter 5160-10 of the Administrative Code, with the following stipulations:
(1)
The provider must:
(a)
Apply to, and be
approved by, the Ohio department of medicaid (ODM) to be eligible to dispense
medical supplies/durable medical equipment; and
(b)
Use the same
medicaid provider number as when billing for pharmaceuticals;
and
(c)
Be licensed, registered, or exempt from licensure or
registration under Chapter 4761. of the Revised Code to bill for home medical
equipment that is subject to regulation under Chapter 4752. of the Revised
Code.
(2)
All products require a prescription written by a
practitioner authorized to prescribe. The prescription must be obtained by and
kept on file at the pharmacy.
(B) Claims submission and billing.
(1)
Medical supplies/durable medical equipment is billed in the
appropriate claim format designated by ODM for those services.
(2)
Medical supplies,
durable medical equipment, prosthetic, and orthotic devices are billed by
pharmacy providers in accordance with Chapter 5160-10 of the Administrative
Code.
(3)
Medical supplies are billed by eligible providers of
pharmacy services only, except as specified in paragraph (C) of this rule.
Eligible providers of pharmacy services may bill for these items without
applying to ODM for eligibility for dispensation of medical supplies/durable
equipment as described in Chapter 5160-10 of the Administrative Code. The list
of supplies is located on the ODM pharmacy website at
https://pharmacy.medicaid.ohio.gov.
(4)
Quantities billed should equal the number of items
dispensed (e.g., the quantity of test strips billed should equal the number of
individual test strips, not the number of boxes).
(5)
The medical
supplies document "Pharmacy benefits: medical supplies and durable medical
equipment products" is located on the ODM pharmacy website and includes five
columns indicating supply item coverage and payments. The supplies in the
document are billed through the pharmacy point of sale claims system using the
national drug code (NDC) on the container from which the product was
dispensed.
(a)
Payment is the lesser of the submitted charge or the
calculated allowable. The calculated allowable is the medicaid maximum
payment.
(b)
The calculated allowable is the medicaid maximum
payment plus the professional dispensing fee applicable to the provider as
described in paragraph (E)(1)(b) of rule
5160-9-05 of the Administrative
Code.
(C) Exceptions to pharmacy billing requirement.
(1)
Contraceptive supplies listed in the appendix to this
rule may be billed by both pharmacy providers and providers eligible to bill in
accordance with rule
5160-10-01 of the Administrative
Code. Pharmacy provider should bill through the pharmacy point of sale claims
system using the NDC on the container from which the product was
dispensed.
(2)
Supplies billed to medicare as the primary payer and
crossed over to medicaid using the medicare crossover process described in
paragraph (B) of rule
5160-1-05 of the Administrative
Code may be billed by any provider eligible for the medicare crossover
process.
(D) Preferred medical supplies.
(1)
Selected products
from the medical supply categories included in the appendix of this rule are
designated as preferred brands, as specified on the ODM website at
https://pharmacy.medicaid.ohio.gov.
(2)
Products that are not designated as preferred supplies
require prior authorization.
(a)
Only the prescribing provider or a member of the
prescribing provider's staff may request prior authorization.
(b)
The prescriber
should document medical necessity for the non-preferred brand and provide the
reason why preferred brand cannot be used.
(c)
When a request
for prior authorization is denied, the recipient is informed in writing of the
denial as well as informed of the right to appeal the denial.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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