Proper Billing of Metric Decimal Package Sizes
Each calendar quarter, Vendor Drug summarizes all of the paid claims data by National Drug Code (NDC) number and bills the drug companies for their products. The drug company pays the invoice but could have questions about Texas' reported utilization. If this occurs, the rebate auditors provided by Vendor Drug's rebate administrator, First Health Services Corporation (FHSC), will review the claims level data for that specific NDC.
Many NDCs are packaged in a size that is not a whole number. When entering a claim for a drug that is packaged in a metric decimal sized package (i.e. 10.2, 2.5, 6.8 etc.), be sure to include the decimals on your claims and do not round up. For example, Symbicort (00186-0370-20) is a 10.2 gm inhaler. When you dispense one inhaler, you should be entering 10.2 in the "Quantity Dispensed" field (442-F7). The same goes for drugs like the Atrovent HFA Inhaler (NDC 00597-0087-17) where the package quantity is 12.9 gm for 1 inhaler. When dispensing ophthalmic drops be sure to include the decimal quantity and do not round up.
When the decimal is omitted, or the quantity rounded up to the next whole number, the drug manufacturer disputes the claim. If a manufacturer disputes a claim, FHSC will contact the dispensing pharmacy for clarification. If the pharmacy has made an error, and the service date of the claim is within the 90 day filing period, the pharmacy can reverse the original claim and resubmit the corrected claim. If the claim is over 90 days, FHSC will ask Vendor Drug to reverse the claim and resubmit it with the correct information.
Some of the common reasons claims are disputed include:
- The quantity claimed does not match the package size (14.5-grams claimed and the NDC is for a 17-gram inhaler);
- Excess quantity - this can be valid, a key punch error, or the pharmacy was billing using the wrong unit of measure (entered 300 in the quantity and the price is for 30);
- Low reimbursement - this can be because of Maximum Allowable Cost (MAC) pricing, key punch errors, or billing in the wrong unit of measure.
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CHIP Drug Rebate Program
The 76th Texas Legislature directed the Health and Human Services Commission (HHSC) to develop a program under the federally authorized State Children's Health Insurance Program (CHIP) (Title XXI of the federal Social Security Act, 42 U.S.C. §§ 1391aa-1397jj). CHIP is an optional program designed to provide affordable insurance to low- to middle-income families with uninsured children.
This CHIP rebate agreement requires drug manufacturers to provide pricing data to the state on a quarterly basis. Quarterly pricing data should be submitted to rebate@fhsc.com. The information is used to calculate the unit rebate amount pursuant to the terms of the contract, and the resulting rate is used to generate quarterly rebate invoices. Utilization for CHIP is invoiced in two parts, based on the funding sources for the program. The largest portion of the CHIP utilization is jointly funded (state and federal participation). A much smaller portion of the CHIP utilization is for the state-only funded portion of CHIP, which covers legal immigrants that are not yet eligible for the jointly funded portion of the program.
Manufacturers wishing to participate in the CHIP rebate program may download the CHIP Drug Rebate Agreement, complete and sign, and return two originals to Provider Synergies, LLC. Please refer questions regarding the CHIP rebate program to the Texas Contract Manager at (513)774-8500. Signed contracts should be returned to:
Texas Contract Manager
Provider Synergies, L.L.C.
5181 Natorp Blvd., Ste 205
Mason, OH 45040 |
Kidney Health Care (KHC) Rebate Program
Children with Special Health Care Needs (CSHCN) Services Rebate Program
Texas Health and Safety Code §§12.025 requires HHSC to establish a voluntary drug rebate program for all drug manufacturers whose products are covered by Kidney Health Care (KHC) and Children with Special Health Care Needs (CSHCN) Services Program. The 77th Texas Legislature General Appropriations Act, TDH Rider 38, authorized KHC and CSHCN to receive and use all rebate monies for client services, and to establish a preference for products from manufacturers who have signed rebate agreements with the program. KHC and CSHCN are committed to ensuring a 100 percent participation rate because of increased drug costs that have significantly impacted program budgets.
The Kidney Health Care program provides wrap-around Part D coverage for eligible clients. CMS has classified this program as a State Pharmaceutical Assistance Plan (SPAP). Manufacturers wishing to participate may download the KHC rebate agreement or CSHCN rebate agreement, complete and sign, and return two copies of each contract. Returned agreements should be addressed to:
Stephanie Abernathy
First Health Services Corp.
4300 Cox Road
Glen Allen, VA 23060 |
