A prescription is required for HHSC to process pharmacy claims for clients enrolled in fee-for-service Medicaid, the CSHCN Services Program, and KHC Program. HHSC does not require the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form (TMHP Form F00030) for products dispensed by a pharmacy.
The claim system will reject products submitted as part of a multi-ingredient compound claim with NCPDP error code 70 ("Product/Service Not Covered") and include the message "LHHS products are not covered in a compound claim" in the "Additional Message Information" field (526-FQ).
The claim system will reject claims if the submitted quantity exceeds the maximum unit per filling with NCPDP error code 9G ("Product/Service Not Covered"). If the quantity submitted exceeds the maximum unit per month, the claim system will reject claims with NCPDP error code 76 ("Plan Limitation Exceeded").
If the claim exceeds quantity limits, pharmacy staff must attest the submitted quantity is the actual quantity prescribed based on medical necessity by submitting the following values:
| Field Name | Field Number | Value |
|---|---|---|
| Submission Clarification Code | 420-DK | 2 (Other override) |
| Prescriber ID | 411-DB | 10-digit National Provider Identifier |
Refer to the NCPDP B1 Transaction Payer Sheet for submission requirements.
Refer to the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook chapter of the Texas Medicaid Provider Procedures Manual (tmhp.com/resources/provider-manuals/tmppm) for quantity guideline criteria. Refer to the table below for limitations impacting claims paid by HHSC.
| Product | Fee-for-service limitations |
|---|---|
| Aerosol Holding Chamber (for use with a metered-dose inhaler) |
|
| Blood Glucose Monitor (Talking) |
|
| Blood Glucose Strips (for monitor) |
|
| Blood Glucose Test Strips with Disposable Monitor |
|
| Hypertonic Saline Solution 3% |
|
| Hypertonic Saline Solution 7% |
|
| Insulin Needles |
|
| Insulin Syringes (1 cc or less) |
|
| Lancets |
|
| Nasal Saline Spray |
|
| Oral Electrolyte Replacement Fluid |
|
| Spring-powered Device for Lancets |
|
Claims for Medicaid do not count towards a client's three prescription-per-month limit. Claims for KHC will count towards a client's four prescription-per-month limit.
HHSC bases its reimbursement rates on the "Home Health DME" Provider Type in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule and does not reimburse pharmacies a dispensing fee or delivery incentive. Refer to the Static Fee Schedules (public.tmhp.com/FeeSchedules/StaticFeeSchedule/FeeSchedules.aspx) page for the individual reimbursement rates.
HHSC does not require the TMHP DME Certification and Receipt Form (Form F00018) for pharmacy claims.