DME Billing
Overview
Drugs administered in the doctor's office, inpatient hospital, outpatient hospital, or any location other than the client's home, nursing facility, or extended care facility are not a covered Vendor Drug Program benefit. Physician-administered drugs must be provided by the medical provider at the time of administration. Pharmacies are encouraged to provide take-home self-administered durable medical equipment (DME) and medical supplies to Medicaid clients.
DME Provider Enrollment
To participate as a DME provider, pharmacies must complete the enrollment application available at tmhp.com. For assistance contact the TMHP Contact Center at 1-800-925-9126 or e-mail TMHP Provider Relations to request assistance from the local TMHP provider relations representative in your area.
All claims for DME items require a completed Title XIX Physician Order form:
For clients enrolled in Medicaid managed care health plans, pharmacies must enroll with their individual health plans for reimbursement, including Superior Foster Care managed care plan.
Comprehensive Care Program
The Medicaid Comprehensive Care Program (CCP) can cover medically necessary drugs and supplies that are not available through Vendor Drug for clients from birth through 20 years of age. Pharmacies not enrolled with CCP should direct the client to call TMHP at 1-800-335-8957 to locate a CCP provider.
Pharmacies that want to enroll should complete an application at tmhp.com. For assistance contact the TMHP Contact Center at 1-800-925-9126, or e-mail TMHP Provider Relations to request assistance from the local TMHP provider relations representative in your area.
Participation allows pharmacies to bill TMHP for medically necessary drugs, equipment, or supplies that are not covered by Vendor Drug (e.g. some over-the-counter drugs, nutritional products, and disposable or expendable medical supplies commonly found in pharmacies).
Prior authorization requirements for services through CCP are found in the TMHP Texas Medicaid Provider Procedures Manual or from the TMHP Prior Authorization CCP unit at 1-800-846-7470.
All CCP services require prior authorization.
For clients enrolled in Medicaid Managed Care health plans, pharmacies must enter into a contract with the client’s individual health plans to be reimbursed for DME and medical supplies or CCP services.
Provider Training
TMHP offers a number of free training seminars each year. All pharmacy staff can view a schedule and register for upcoming workshops at tmhp.com. A free computer-based training module for pharmacy DME providers is available through the TMHP Learning Management System (LMS).