Sample Selection and Records Request Processes

PERM is implemented by the Centers for Medicare and Medicaid Services (CMS), primarily using its contractors, (a) The Lewin Group and (b) A Plus Government Solutions Inc.  Claims will be randomly selected by The Lewin Group and reviewed by A Plus Government Solutions Inc.’s subcontractor, Health Data Insights (HDI).  

If your pharmacy has a claim that is selected for review, you will receive a series of communications, including the following:

  • A Health and Human Services Commission (HHSC) representative will call to verify your contact information (such as mailing address, fax number, and e-mail address).
  • A Plus Government Solutions Inc. representative will call to ask if you prefer to receive the written review notice by fax or by mail.
  • A Plus Government Solutions Inc. representative will send a review notice with the selected claim(s) and request copies of your supporting pharmacy records for each claim.

Pharmacies will be required to provide pharmacy records to support sampled Medicaid and CHIP claims.  Pharmacy records are defined primarily as copies of the front and back of the original prescription or a copy of the nursing home chart order.  All copies must include the prescription number.  Acceptable documentation includes:

  • Copy of Prescription: Original, facsimile, or telephonic.  Front and back (if applicable) with patient name, date of birth, address, telephone number, and physician name.
  • Physician medication order for skilled nursing facility/nursing facility (SNF/NF) or Intermediate Care Facility for Mental Retardation (ICF/MR).

In addition, PERM reviewers will check to ensure that pharmacy records include the following information, as applicable: 

  • National drug code (NDC) Number.
  • Drug Enforcement Administration (DEA) number for controlled substances.
  • Prior authorization, if required.
  • Member pharmacy signature log / proof of delivery.
  • Proof of delivery to nursing home.
  • Nursing home pharmacist drug regimen review. 

Please note: Copies of prescription labels are not considered a pharmacy record and will not be accepted or evaluated by the reviewers.

If the copy of the prescription or nursing home chart order you submit does not include all required information, you may receive a second written request from A Plus Government Solutions Inc. to provide additional information to the reviewers.

Deadlines for Providing Requested Pharmacy Records

HHSC anticipates reviews, and related requests for records, to begin later this fall 2011.  Providers must submit requested pharmacy records to both (a) A Plus Government Solutions Inc. and (b) HHSC, within 75 calendar days of the receipt of the written notice of request from A Plus Government Solutions, Inc.  HDI will review the information submitted to determine whether the sampled claims was fully supported and paid accurately.  HHSC will maintain a copy of your pharmacy records to evaluate in the event one of your claims is identified as a potential PERM exception by the reviewers.

In the event you/providers receive a request for additional information that may help support that reimbursement for the sampled claim was accurate, you/providers must submit the requested information to both (a) A Plus Government Solutions Inc. and (b) HHSC, within 14 calendar days of the receipt of the written notice of request from A Plus Government Solutions, Inc.

Failure to Timely Provide Complete and Accurate Pharmacy Records

If providers fail to respond or fail to produce complete and correct documentation for a selected claim within the original time frame, A Plus Government Solutions Inc., will identify the claim as a PERM exception.  Providers will be required to reimburse the total amount paid for the claim in accordance with state and federal requirements.  In addition to this direct impact to providers, high error rates among pharmacies could negatively impact the amount of federal funding Texas receives for Medicaid and CHIP. 

If you have a question about a request for information, do not delay obtaining an answer to your question.  A quick response will help to avoid an exception for failing to timely respond with complete and accurate information.  Providers with questions about the request for pharmacy records should contact A Plus Government Solutions Inc. immediately at (703) 682-0820. 

Provider Contact Information Must Be Accurate

If your pharmacy has a claim that is selected for review, and A Plus Government Solutions Inc. is unable to establish contact with you because your contact information maintained in Vendor Drug Program records contains an incorrect phone number, fax number, or address, the claim will automatically be considered a PERM exception, and you will be required to reimburse the total amount paid for the claim, again in accordance with state and federal requirements.

It is an HHSC contract requirement for providers to notify the Medicaid/CHIP Contracts section of any change in phone number, mailing address, or physical address.  All providers should check the “Pharmacy Contracts” section of the Vendor Drug website to ensure their contact information is correct.  If the information is incorrect or incomplete, providers must fax the updated information on your pharmacy letterhead to the Medicaid/CHIP Contract Management Unit at 512-491-1974. 

Provider participation of the PERM review process is required.  The Vendor Drug Program appreciates the additional effort this will require.