Medicaid Recipients Eligible for Medicare Part D
In June 2009, a new message was returned on paid claims for clients who will soon become eligible for Medicare Part D. This message will be returned several months prior to the client's Medicare coverage effective date to alert the pharmacy that Medicare will become liable for the client's prescription drug coverage. Please advise the client that Medicaid will no longer pay for prescriptions for Part D covered drugs as of the date included in the message.
CMS Medicaid Integrity Group Audit
The Centers for Medicare and Medicaid Services Medicaid Integrity Group (CMS-MIG) began auditing the Texas Medicaid Program in spring 2009. A Medicaid Integrity Contractor (MIC), Health Management Systems (HMS), is auditing outpatient prescription drug claim payments submitted by some Texas Medicaid pharmacy providers. The audit is designed to identify instances of fraud, abuse, or waste, including overpayments to individuals or entities for prescriptions or other items.
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Prescriber National Provider Identifier (NPI)
Support for the voluntary submission of the prescriber’s National Provider Identifier (NPI) will not be implemented on July 15, 2009. Please continue to submit the prescriber’s state license number in "Prescriber ID" (Field 411-DB) on all claim transactions.
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Cost Avoidance
The Vendor Drug Program moved from a pharmacy "pay and chase" model to a pharmacy "cost avoidance" model, thereby ensuring that third party insurance pay for clients' prescription drug services first and that Medicaid is the payer of last resort. Phase I of this project began January 20, 2009 and only included a limited number of adults age 21 and over. Phase II began July 20, 2009 and included the entire Medicaid population (adults and children).
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Automated Function Adjudicates Medicaid Retroactive Claims
In the past claims rejected with National Council for Prescription Drug Programs (NCPDP) error 81 ("Claim Too Old") if they were submitted more than 90 days after the prescription date, even for clients that became retroactively eligible for Medicaid. A paper/fax process followed to obtain reimbursement. Vendor Drug implemented a new process on June 30, 2008 that will allow claims to process online for 90 days after the certification date of retroactive eligibility if the date of service is within the retroactive coverage period.
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Payment Error Rate Measurement (PERM)
In 2008, the Centers for Medicare & Medicaid Services (CMS) began the Payment Error Rate Measurement (PERM) review process to measure the accuracy of payments in Medicaid and the Children's Health Insurance Program (CHIP) in Texas. During this review process, a CMS federal contractor will review a random sample of Medicaid and CHIP pharmacy claims to determine if they were paid correctly.
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Provider National Provider Identifier (NPI)
The Centers for Medicaid and Medicare (CMS) requires the pharmacy National Provider Identifier (NPI) to identify pharmacy providers on all standard electronic transactions beginning May 23, 2008.
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Tamper Resistant Prescription Pads
Effective April 1, 2008, pursuant to federal law prescribing practitioners will be required to use tamper-resistant prescription paper when writing a prescription for any drug for Medicaid recipients.
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STAR Health (Program for children in Foster Care)
In April 2008, the Texas Health and Human Services Commission launched STAR Health, a new health-care program to improve services and better coordinate health care for children in foster care.
Texas Women's Health Program
The Texas Women’s Health Program began January 1, 2007 and provides gynecological exams, related health screenings, and contraception through Texas Medicaid at no cost to eligible women. Prescription drug coverage in the program is limited to contraceptive birth control, excluding emergency contraception. Claims submitted with ineligible products will reject with NCPDP error code 70 ("Product/Service Not Covered") with an additional message, "Product not covered by Women's Health Program."
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CHIP Perinatal Project
The CHIP Perinatal Program began January 1, 2007 to provide prenatal care for the unborn children of low-income women who do not qualify for Medicaid. Women and infants in the program will each have a 9-digit CHIP Cardholder number starting with an alpha character.
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Medicare Part D
Medicare Part D is a prescription drug benefit that began January 1, 2006. Part D offers optional drug coverage to all Medicare beneficiaries through private drug plans (PDPs) or Medicare Health Maintenance Organizations (HMOs).
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Medicaid Preferred Generics
Effective December 1, 2004, Vendor Drug began the payment of a $0.50 incentive to contracted pharmacies that use a Premium Preferred Generic Drug (PPG) to fill Medicaid prescriptions. Generic prescriptions filled with non-PPG drugs are not penalized in any way, but are not eligible for the $0.50 incentive. All PPG and non-PPG drugs are subject to the Clinical and Therapeutic Edits Program. PPG drugs can be found on the Medicaid Preferred Drug List or via the Texas Drug Code Index Formulary Drug Search.
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Children's Health Insurance Program
On March 1, 2002, the Texas Medicaid Vendor Drug Program began administering the outpatient drug benefit on behalf of CHIP . Prescription drug claims must be submitted electronically through the Vendor Drug Program. |
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