Current through all regulations passed and filed through September 16, 2024
(A) The pharmacy claims submitted to the Ohio department of medicaid (ODM)
or its designee, the pharmacy point-of-sale vendor, must reflect the actual
national drug code (NDC) on the container from which the product was
dispensed.
(B) All records of
prescriptions must comply with federal and state regulations and
be retained by the provider for a
period of six years from the date of payment of the claim and if an audit is
initiated during this time, records must be retained until the audit is
resolved.
(C) For a pharmacy claim
to be eligible for payment by ODM, any prescription executed in written (and
non-electronic) format must be executed on a tamper-resistant form.
(1) To be considered tamper resistant, a
prescription form must contain all of the following three characteristics:
(a) One or more features designed to prevent
unauthorized copying of a completed or blank prescription form;
(b) One or more features designed to prevent
the erasure or modification of information written on the prescription by the
prescriber; and
(c) One or more
features designed to prevent the use of counterfeit prescription
forms.
(2) The
tamper-resistant requirement applies to all written prescriptions presented at
the pharmacy when ODM pays any part of the claim, including when ODM is not the
primary payer, in accordance with paragraphs (F) and (G) of this
rule.
(3) The tamper-resistant
requirement does not apply in the following situations:
(a) Prescriptions transmitted to the pharmacy
via an electronic prescription transmission system, facsimile device, or
telephone, in accordance with rules promulgated by the state board of pharmacy
in agency 4729 of the Administrative Code;
(b) Orders for medications administered in a
provider setting and billed by the administering provider in accordance with
paragraph (H) of rule
5160-9-03 of the Administrative
Code; or
(c) Orders for medications
administered in a nursing facility (NF) or intermediate care facility for
individuals with intellectual disabilities (ICF/IID), if the order is written
in the
recipient's medical record and given by medical staff
directly to the pharmacy. The prescription is considered tamper resistant if
the
recipient does not have opportunity to handle the
written order.
(4) If a
written prescription that is not tamper resistant is presented at the pharmacy,
the pharmacy may fill the prescription on an emergency basis and obtain a
compliant tamper-resistant replacement from the prescriber within seventy-two
hours of dispensing.
(a) A tamper-resistant
replacement may be obtained via any of the following methods:
(i) Telephone verification from the
prescriber or prescriber's staff, documented on the prescription with the name
of the person at the prescriber's office verifying the prescription, date of
verification, and identification of the pharmacist or pharmacy staff member
requesting verification;
(ii)
Obtaining a copy of the prescription from the prescriber via facsimile
device;
(iii) Obtaining an
electronic prescription from the prescriber; or
(iv) Obtaining a replacement written
prescription from the prescriber on a tamper-resistant form.
(b) The replacement
tamper-resistant prescription shall be filed with the original,
non-tamper-resistant prescription.
(c) The dispensing pharmacist shall use
professional judgment to define an emergency situation.
(5) When it is determined that a
recipient is retroactively eligible, and the
recipient's original or refill prescription was filled
during a period when the
recipient is retroactively eligible, the pharmacy
must ensure that the original prescription was tamper resistant before billing
the pharmacy claim to ODM.
(a) If the
prescription meets the provisions of paragraph (C)(3) of this rule, the
tamper-resistant requirement does not apply.
(b) If the original prescription was not
tamper resistant, the pharmacy may obtain a tamper-resistant replacement as
described in paragraphs (C)(4)(a) and (C)(4)(b) of this rule.
(D) Claims for drugs
purchased through the 340B drug discount program as defined in
section 340B(a)(4) of the "Public Health
Service Act,"42 U.S.C.
256b(a)(4) (as in effect as
of January 7, 2011) are submitted with the provider's actual acquisition
cost plus cost of dispensing, and use
the codes described in billing instructions issued by ODM or its
designee.
(E) Voids and reversals
(1) Return to stock
(a) When
recipients
fail to pick up their prescriptions, pharmacies must reverse the claim
submitted to ODM as soon as possible and not later than
fourteen days after preparation.
(b) When prescriptions
were dispensed to a resident of a NF or ICF/IID and
there is an unutilized portion of a legally redispensable drug remaining, the
drug must either be:
(i) Destroyed;
or
(ii) Returned to the pharmacy to
be redispensed and the product cost, not including the dispensing fee, must be
credited to ODM by
voiding or reversing the original claim and submitting a new claim for the
utilized amount plus dispensing fee.
(2) Voids, reversals, and replacement claims
for other reasons
(a) Original claims
should
be submitted within three hundred sixty-five days of the date of service.
Claims may be reversed, voided, or replaced (i.e., re-billed) at any time
within the first three hundred sixty-five days after the date of
service.
(b) Claims may be
reversed, voided, or replaced beyond three hundred sixty-five days after the
date of service in the following circumstances:
(i) Adjudicated paid claims may be reversed
and replaced (i.e., re-billed) beyond three hundred sixty-five days after the
date of service if the adjudication date of the replacement claim is within
ninety days after the date of original claim payment.
(ii) Adjudicated denied claims may be
replaced (i.e., re-billed) beyond three hundred sixty-five days after the date
of service if the adjudication date of the replacement claim is within ninety
days after the date of adjudication of an original denied claim.
(iii) Adjudicated paid claims may be reversed
or voided beyond three hundred sixty-five days after the date of service if the
adjudication date of the reversal or void is within five hundred forty-five
days after the date of original claim payment.
(F) Third party liability
(1) In accordance with rules
5160-1-17.2 and
5160-1-08 of the Administrative
Code, ODM is the payer of last resort.
(2) The provider's claim shall include the
following indicators for each third-party payer as described in billing
instructions issued by ODM or its designee.
(a) A payer identification code;
(b) Whether the claim was approved or denied,
and if denied the reason for the denial;
(c) All amounts paid by third-party payers;
and
(d) The
recipient
's responsibility amount assigned by each payer.
(G) Medicare part B-covered
services
Drugs covered by medicare part B for dually eligible
recipients
will first be billed by the provider to medicare.
When appropriate, ODM pays the medicare part B cost sharing in accordance with
rules 5160-1-05 to
5160-1-05.3 of the
Administrative Code. Cost sharing for medicare part B services
should
not be billed in a pharmacy claim format and
should be
billed in accordance with the billing instructions issued by ODM for
professional claims billed secondary to medicare part B or medicare part
C.
(H) Medicare part
D-covered services
Drugs that are covered or are eligible to be covered by
medicare part D for dually eligible
recipients
are not covered by medicaid. Medicaid does not pay medicare cost sharing for
medicare part D services.
(I)
Provider types
described in rule
5160-9-01 of the Administrative
Code are required to submit a complete response to the cost of dispensing
survey conducted according to section
5164.752 of the Revised
Code.
(1)
A
complete response to the cost of dispensing survey includes supplying complete
information about the terminal distributor for, at the least, all of the
following categories:
(a)
Demographics;
(b)
Number of
prescriptions dispensed annually, broken out by medicaid fee-for-service and
other payers, and including a total volume for the location;
(c)
Sales and cost of
goods sold;
(d)
Direct expenses;
(e)
Overhead
expenses; and
(f)
Certification that the person submitting the survey
believes the information to be true, correct, and complete.
(2)
Providers that do not submit a complete response to the cost
of dispensing survey may be paid a lower professional dispensing fee (PDF) in
accordance with rule
5160-9-05 of the Administrative
Code.
(3)
Newly-enrolled providers are assigned to the dispensing
fee described in rule
5160-9-05 of the Administrative
Code.
(a)
If the
provider received the new provider number due to a change in ownership, the
department uses the number of prescriptions reported by the previous ownership
to determine the PDF.
(b)
In a situation other than a change of ownership, a
provider is newly enrolled if the date of approval for an application to enroll
as a provider, or the date of approval of a specialty pharmacy designation, is
less than ninety days prior to the distribution of the most recently conducted
cost of dispensing survey then the date of approval is not the effective date
of the provider agreement or specialty designation when the effective date is
made retroactive by ODM.
(4)
If a provider
experiences a change in prescription volume during the first nine months
following the implementation of a PDF category significant enough that it would
result in the provider falling into a different PDF category, the provider may
submit a written request with supporting documentation to ODM, no later than
the thirtieth day of April of the first year, requesting assignment to a
different category. If the supporting documentation justifies an adjustment,
ODM will assign a new PDF category effective the first day of July for the
second year.
