Field Administration

Vendor Drug Field Administration provides pharmacy education, technical support, and training and reviews claims activity to ensure compliance with contracts and program policy.

Desk reviews are conducted monthly for the purpose of monitoring compliance of three types of paid outpatient pharmacy claims:

• High Dollar claims (total paid is equal to or greater than $1500.00)
• Maximum Allowable Cost (MAC) claims (physician override reported, and total paid is greater than $30)
• Compound drug claims

Claims are selected for review at the discretion of Vendor Drug Program regional pharmacists. 

The monthly desk review mailing consists of a standard letter and a report listing prescription copies requested.  A check-mark in the left margin of the report indicates that a copy of the prescription is requested.  Copies of prescriptions are requested only once, at the time of the original fill.  If a valid copy of an original fill prescription is not received, all subsequent fills (refills) are automatically debited.

Pharmacies have 25 calendar days from the date of the letter to reply.  If requested copies of high dollar claims are not returned, or the copies do not meet the criteria by the deadline, pharmacies will be notified by phone, fax, or email.  Due to overall desk review volume, Vendor Drug staff is unable to notify pharmacies of MAC and compound claims that do not meet desk review criteria.  Pharmacies are given until the close of business the following day to return the requested information.  If the copies are not provided, or the criteria are not met, the claims will be adjusted or debited.

Criteria

All prescription copies must be valid prescriptions as defined by the Texas State Board of Pharmacy (TSBP).  The Prescriber ID number, prescription written date, date of service, drug name, drug quantity, and day supply must match the claim.

• High dollar prescription copies must be of an original prescription signed by the prescriber.
• Compound prescription copies must show both the quantity and National Drug Code (NDC) number for each ingredient on the claim.
• Copies of MAC prescriptions for which a “dispense as written” override was used require one of the following phrases written across the face of the prescription in the prescriber's handwriting: "Brand Necessary," "Brand Medically Necessary," "Brand Name Necessary," or "Brand Name Medically Necessary".  This is a federal and state law that applies to all MAC claims – including electronic prescriptions/e-scripts.  A typed or printed “brand” statement is not acceptable, nor is a statement obviously not written in the prescriber’s own handwriting.
• In the e-prescription transaction to the pharmacy, the prescribing physician must select the option for “Dispense as Written” (DAW) on the electronic prescription pad and enter “Brand Medically Necessary” in the “Notes to Pharmacy”.  If an e-prescription is received by a pharmacy with DAW indicated but without the free text message or additional note, the pharmacist must contact the prescriber for a new prescription.  Once the pharmacy receives the e-prescription with both of these data elements, the prescription should be transmitted to Vendor Drug in the standard NCPDP Billing Request format with the following:

• “1” in “Dispense as Written” (Field 4Ø8-D8).
• “3” in “Prescription Origin Code” (Field 419-DJ).
• The presence of “Brand Medically Necessary” in the free text field will be subject to review by the Vendor Drug Program beginning September 1, 2011. There is no need for a physical signature on an e-prescription, including those that cost $1,500 or more. Medicaid will accept an e-prescription if we can determine that it was electronically transmitted by way of the unique identifier number assigned to the transaction for either the prescriber or the pharmacy. However, e-faxes for prescriptions over $1,500 do require a handwritten signature as part of the faxed document.
• Failure of the pharmacy to produce electronic records that indicate the proper DAW and “Brand Medically Necessary” in the free text message for the prescription will result in the claim being subject to recoupment.  All non-electronic “Brand Medically Necessary Prescriptions” must continue to comply with the current policy as outlined in the VDP Pharmacy Provider Procedure Manual with applicable Texas State Board of Pharmacy rules.

Other Information

Nurse Practitioner or Physician Assistant signatures are acceptable, provided the supervising doctor’s demographic information, including license number, is on the prescription. Registered Nurse signatures or initials are not acceptable as they do not have prescriptive authority in the state of Texas.

Refill authorization requests are acceptable as long as all criteria for a new prescription are met.  Pharmacy transfer requests are acceptable, but a copy of the original prescription is required.  Telephoned prescriptions are acceptable as long as all criteria for a new prescription are met.  Faxed prescriptions are acceptable; however TSBP rules state that faxed prescriptions must include a statement that indicates the prescription has been transmitted via facsimile.

Continuing Education information
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