Texas Medicaid/CHIP Drug Vendor Program News

Co-payments to Increase for Some CHIP Recipients

February 17, 2012

Effective March 1, 2012, the co-pay level for some recipients enrolled in the Children’s Health Insurance Program (CHIP) will increase for generic and brand name prescription drugs.  The co-pay amount due is returned in “Patient Pay Amount” (Field 5Ø5-F5) on the paid response.  Recipients and health plans have been notified of this change.

Families with incomes above 150 percent of the federal poverty level will see their co-payments for generic prescriptions drugs increase from $8 to $10.  For brand-name prescriptions drugs, the co-pay will increase from $25 to $35.

Please Note: After March 1, the designation of a drug as generic or brand may vary between managed care plans.  Therefore, the co-pay amount may vary for the same drug for clients in different plans.

To learn more about the Vendor Drug Program please visit txvendordrug.com.

Pharmaceutical & Therapeutics Committee Recommendations Posted

February 13, 2012

The Pharmaceutical and Therapeutic Committee's recommendations made at the January 2012 meeting regarding which drugs to place on the Medicaid Preferred Drug List have been posted.

Medicaid/CHIP Vendor Drug Program – Payment Update

February 13, 2012

There will be a one-day delay in direct deposits to pharmacy providers for Medicaid and the Children’s Health Insurance Program because of the President’s Day federal holiday on Monday February 20, 2012.  Claims submitted February 10 through February 16, will be paid February 23, 2012.  Claims submitted February 17 through February 23 will resume on the regular cycle and will be available on February 29.

Rx Update Available

February 10, 2012

The latest edition of the Vendor Drug newsletter, the Rx Update, is now available.

Preferred Drug List Changes effective January 25, 2012

January 24, 2012

The Texas Health and Human Services Commission Vendor Drug Program will implement changes to the Medicaid Preferred Drug List (PDL) on Wednesday, January 25, 2012.  The PDL includes the Cough/Cold and Prenatal Vitamins list.  Pharmacies should never automatically switch a preferred brand medication to a non-preferred generic equivalent NDC.  This is most common with cough and cold preparations.

Please note that there are some brand name products designated as “preferred” within a therapeutic category for which there are generically equivalent products available. Two examples in the current Preferred Drug List are Zyprexa and Toprol XL.  The branded drugs in these cases provide the best value to the state, after rebates. These drugs are preferred and require no prior approval or Brand Name Necessary prescription.  The generic counterparts are non-preferred and require a prior authorization.  Pharmacies should never automatically switch a preferred medication to a non-preferred generic product requiring prior authorization or require a Brand Name Necessary prescription.  In instances when a brand name drug is on the formulary but the generic equivalent is not, a Brand Name Necessary prescription is not required.

The PDL also is available on the Epocrates drug information system, which provides access to the list from your digital handheld devices.  The system also provides clinical information, including a drug monograph, dosing and warnings.  To learn more about this service, please visit txvendordrug.com.

Vendor Drug to Edit on Patient Last Name

January 13, 2012

All pharmacies seeking reimbursement for claims must include the client’s last name in the appropriate field or the claims will be rejected.  Pharmacies have been calling the Vendor Drug Pharmacy Resolution Help Desk to report problems with the Patient Last Name field.  Most of those problems can be avoided if the claim is properly submitted and the last name is entered into the appropriate field.

On January 25, 2012, claims will begin to reject if the last name submitted in the “Patient Last Name” field (311-CB) does not match the last name on file with Vendor Drug. This is now a required field in the National Council for Prescription Drug Programs (NCPDP) D.Ø format.  Please check the client’s Your Texas Benefits Medicaid Card or program-specific card, to ensure you are submitting the correct last name.  If an incorrect name is submitted, the claim will reject with error code “62” (Patient/Card Holder ID Name Mismatch).  If the name on file with Vendor Drug is incorrect in the system, please refer the individual to his or her caseworker to have the system of record updated.

Beginning February 1, 2012, the Vendor Drug Program will accept transactions only in the National Council for Prescription Drug Programs (NCPDP) version D.0 format and will reject transactions submitted in version 5.1.  Vendor Drug began accepting version D.0 transactions on December 1, 2011.

Pharmaceutical & Therapeutics Committee Decisions Posted

January 12, 2012

High-Volume Pharmacies to Educate Employees about Fraud

January 2, 2012

Federal law requires all providers and other entities that receive or make annual Medicaid payments of $5 million or more to educate their employees, contractors, and agents about fraud and false claims laws and the whistleblower protections available under those laws.  To learn more please visit the Texas Medicaid website.

NCPDP Version D.Ø Claim Submission Reminders

December 30, 2011

Beginning February 1, 2012, the Vendor Drug Program will only accept transactions in the National Council for Prescription Drug Programs (NCPDP) version D.Ø and reject transactions submitted in version 5.1.  Vendor Drug began accepting version D.Ø transactions on December 1, 2011.  Our Pharmacy Resolution Help Desk reports the following issues that some pharmacies are having with the new format:

• The values accepted for “Group ID” (Field 3Ø1‐C1) are “MEDICAID”, “CHIP”, “KHC”, or “CSHCN”.
• Some pharmacies are unfamiliar with the new error codes returned on D.Ø transactions.  Please refer to the VDP Pharmacy Provider Procedure Manual, specifically Attachment A: Standard Format Reject Codes.  Please note this list contains only the error codes returned by Vendor Drug and is not a full list of all codes available in the new format.

Pharmacy Continuing Education

December 27, 2011

Pharmacies contracted with Vendor Drug are in a unique position to help Medicaid recipients with their pharmacy benefits. It’s important for pharmacy staff to know what pharmacy items that Medicaid pays for, which products require prior authorization, and who to contact with claim processing questions. Our website has more about these and other initiatives and reminders:

• 72-Hour Emergency Overrides for Prior Authorization-Required Drugs
• Free Continuing Education Credits are Just a Click Away
• Comprehensive Care Program Assists Medicaid Children
• Separate Billing for Outpatient Prescriptions and DME
• Temporary Medicaid Eligibility Verification Form (1027-A)
• Medicaid/CHIP IMPROVEs State, Provider Communication
• Client Eligibility Verification Tools for Pharmacy Staff

NCPDP D.0 / HIPAA 5010 Status

December 22, 2011

Vendor Drug began accepting the National Council of Prescription Drug Program (NCPDP) version D.0 billing (B1), reversal (B2), and eligibility verification (E1) transactions on December 1.  Beginning February 1, 2012, pharmacies, software vendors, and switch vendors will only be allowed to submit D.0 transactions. As of that date transactions in the current version 5.1 will reject.  The Vendor Drug test system is available for D.0 testing until January 23, 2012.

Pharmacies will continue to receive the 835 electronic remittance advice transaction file in HIPAA 4010 format until December 26 for claims adjudicated between December 16 and December 22. Starting on the first January payment cycle (January 2, 2012) the 835 file will be in HIPAA 5010 format only. The first 5010 835 file will include claims adjudicated from December 23-29, 2011.  If you are not ready to receive the 5010 format of the 835 file on January 2, the 835 file will remain available on your MoveIT account for up to 30 days.

A test 835 file in 5010 format was delivered to each pharmacy’s MoveIT account on December 9.  If you have not done so already, please review and report any issues to ACS-Pharmacy at pharmacies.5010@tmhp.com.

Additional Managed Care Trainings Available for Pharmacies

December 12, 2011

HHSC is conducting a Medicaid managed care pharmacy benefits webinar for pharmacists and prescribers.  Each 60-minute webinar will provide information on managed care for pharmacy benefits effective March 1, 2012.  Participation is limited to the first 125 callers and you must register to attend.  Please visit the HHSC managed care initiatives page for more information and to view the Pharmacy Benefit provider presentation.

First Session:

Friday, December 16, 2011, 2:30 pm Central

Second Session:

Tuesday, December 20, 2011, 2:30 pm Central

Prescriber NPI Will Be Accepted October 12, 2011

November 1, 2011

On Wednesday, October 12, the Vendor Drug Program began accepting either the prescriber’s 5-character state license number or 10-digit National Provider Identifier (NPI) on all billing requests.  Since that time, the Pharmacy Resolution Help Desk reports an increase in rejections related to how pharmacies are submitting prescriber identifier numbers:

• Prescriptions written by nurse practitioners and physician assistants must be submitted using the license number or NPI of the supervising physician.
• Prescriptions written by interns and residents may be submitted using the license number or NPI of the supervising physician.  They may also use the license number or NPI of their training institution as verified by the Vendor Drug Program.
• If your claim rejects with error code “EZ”, please ensure you are submitting the correct combination of ID number and qualifier in "Prescriber ID Qualifier" (Field 466-EZ) and "Prescriber ID" (Field 411-DB).  Other qualifier values are not supported and will cause the claim to reject. Please refer to payer specification documents within the Pharmacy Provider Procedure Manual for transaction requirements.
• If you submit your claim with the NPI but receive error code “71” or “56”, please attempt to resubmit with the state license number (and appropriate qualifier).  If your pharmacy software does not allow you to submit the state license number, please contact your software provider.

Prescriber NPI numbers are available online, and claims will reject if the submitted NPI is not on file.  If you have any questions about using the NPI please contact the Pharmacy Resolution Help Desk.

CMS Sponsors Online PERM Education Sessions

October 13, 2011

The Centers for Medicare & Medicaid Services (CMS) is hosting a PERM Provider education Webinar/Listening Session to provide an opportunity for the providers of the Medicaid and Children’s Health Insurance Program (CHIP) communities in the Cycle 3 (FY2011) States.

The Payment Error Rate Measurement (PERM) program is designed to measure improper payments in the Medicaid and CHIP programs, as required by the Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act or IPERA).  The purpose of this webinar/listening session is to educate Medicaid and CHIP providers about PERM and their specific responsibilities during the PERM process.  Webinar/Listening Session participants will learn an overview of the PERM Program, the PERM process and provider responsibilities during a PERM review, and frequent mistakes and best practices.

The following materials will be discussed and are available on the PERM Providers page of the CMS Website:

• PERM Overview for Providers
• Sample medical records/service records request letter

Certain Vitamins and Minerals Are CCP Benefit

October 11, 2011

Certain vitamin and mineral products prescribed or ordered by a physician to treat various conditions will be a benefit of Texas Medicaid through the Texas Medicaid Children’s Comprehensive Care Program (CCP) for clients who are 20 years of age and younger. The certain vitamin and mineral products will be billed to TMHP, manually priced, and will be a benefit when they are prior authorized and submitted with the corresponding procedure code and state-identified modifier:  For list of vitamin and minerals, procedure codes, and state identified modifiers, see the Benefit Criteria for Vitamin and Mineral Products to Change for Texas Medicaid article in September/October 2011 edition of the TMHP Texas Medicaid Bulletin.

Provider Transition Training for STAR, STAR+PLUS, Pharmacy,
and Children's Dental Services

September 20, 2011

The Health and Human Services Commission (HHSC) is hosting a series of provider trainings in the Managed Care Expansion service delivery areas. These meetings will allow HHSC to present information ensuring a successful expansion of the STAR and STAR+PLUS Medicaid managed care programs, managed care pharmacy benefits, and Medicaid and CHIP dental managed care. Providers will be given an opportunity to have questions answered relevant to Medicaid services. This will allow providers to make an informed decision on executing contracts with the Managed Care Organizations.

There is no cost to attend these trainings. Trainings are conducted in select cities across the state between September and November 2011 in half-day segments. Please take a moment to complete the registration form to receive location dates and times and meeting confirmation. Registration is requested for each individual who will be attending training.  For additional information please visit the HHSC Medicaid Managed Care initiatives as we move forward to the March 2012 implementation.

KHC to End Coverage of Brand Name Cellcept, Valcyte

September 7, 2011

2011-12 Synagis Season

September 7, 2011

Prior approvals for Synagis will be available through the Vendor Drug Program beginning September 15, 2011.  The start of the 2011-2012 respiratory syncytial virus (RSV) season varies based on a patient’s county of residence, with most areas in Texas beginning October 1, 2011.

Preparing for the 2011 Payment Error Rate Measurement (PERM) Review

August 30, 2011

The Payment Error Rate Measurement (PERM) reviews the accuracy of Medicaid and Children’s Health Insurance Program (CHIP) payments. PERM is implemented by the Centers for Medicare & Medicaid Services (CMS) through its contractors. 

Claims will be randomly selected by The Lewin Group and reviewed by A Plus Government Solutions Inc. and it’s subcontractor, Health Data Insights (HDI).  Pharmacies that have claims selected as part of this year’s review will receive a series of communications from A Plus Government Solutions Inc. and be required to provide pharmacy records to support the sampled Medicaid and CHIP claims.

HHSC anticipates these reviews and the related requests for records to begin later this fall. 

To prepare, pharmacies should first ensure that the contact information on file with Vendor Drug is correct.  Please refer to the “Pharmacy Contracts” section of our website.  If the information is incorrect, please provide corrections to Medicaid/CHIP Contract Management.

The New Your Texas Benefits Medicaid Card

August 29, 2011

This month, HHSC began issuing new Medicaid ID cards to Texas Medicaid clients. The new ID, called the Your Texas Benefits Medicaid card, is a plastic, magnetic-striped card that replaces the paper Medicaid ID (Form 3087).  Texas Medicaid clients will present this card at the pharmacy when picking up or filling new prescription medications.

Some Your Texas Benefits Medicaid cards have QMB printed in the upper-right corner.  This abbreviation denotes clients with Qualified Medicare Beneficiary benefits that do not include prescription coverage.  Do not submit pharmacy claims for payment for clients with the QMB notation on their card.  Claims submitted for these clients will reject because the client does not have prescription coverage through Medicaid.

Pharmacists and other pharmacy staff can use one of the existing Vendor Drug eligibility verification tools to obtain out-patient pharmacy eligibility and prescription benefits data for any client.

Pharmacies Invited to Join Medicaid/CHIP Managed Care Networks

August 25, 2011

By March 2012, the majority of Medicaid and Children’s Health Insurance Program (CHIP) clients will receive their pharmacy benefits from a managed care plan.  HHSC tentatively awarded contracts to several Managed Care Organizations (MCOs) that have teamed up with Pharmacy Benefit Managers (PBMs) to provide benefits in each service delivery area.  Managed Medicaid programs are called STAR, STAR+PLUS, STAR-MRSA, and STAR Health – out-patient drugs will be a benefit of each program and CHIP.

The names of all enrolled Medicaid pharmacies have been provided to the MCOs.  They must consider all Significant Traditional Providers (as found in the link provided below) enrolled pharmacy providers when building their provider network.  Many Texas pharmacies have already been contacted by the MCOs or their PBM.

As HHSC awards managed care contracts, those plans will work to execute contracts with providers.  HHSC encourages pharmacies to engage in contract discussions with the selected MCOs/PBMs.  Please take the time to understand the financial and administrative terms and conditions that are offered.  HHSC wants to maintain a robust provider network in every service delivery area.

To find additional information about the tentative MCO contract awards and information on the procurement, visit the HHSC Business Opportunities site.  Click on the “RFP Documents” link on the same page to see maps of the service delivery areas for each of managed Medicaid programs.

More information about these changes is in the recent edition of the Rx Update.