9.1. HHSC

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)
  • Quantity: 1 unit maximum every 180 days
  • Refills: not limited to 5
Blood Glucose Monitor (Talking)
  • Quantity: 1 unit maximum per three rolling years
  • Refills: not limited to 5
  • Only available for people with visual impairment
Blood Glucose Strips (for monitor)
  • Quantity: 100 units maximum every calendar month
  • Refills: limited to 5
  • Day supply: 30
  • Refill-too-soon utilization: 100%
Blood Glucose Test Strips with Disposable Monitor
  • Quantity: 100 units maximum every calendar month
  • Day supply: 30
  • Refill-too-soon utilization: 100%
  • Refills: limited to 5
Hypertonic Saline Solution 3%
  • Refill-too-soon utilization: 75%
  • Refills: not limited to 5
Hypertonic Saline Solution 7%
  • Refill-too-soon utilization: 75%
  • Refills: not limited to 5
Insulin Needles
  • Refill-too-soon utilization: 75%
  • Refills: not limited to 5
Insulin Syringes (1 cc or less)
  • Refill-too-soon utilization: 75%
  • Refills: not limited to 5
Lancets
  • Quantity: 100 units maximum every calendar month
  • Day supply: 30
  • Refill-too-soon utilization: 100%
  • Refills: limited to 5
Nasal Saline Spray
  • Refill-too-soon utilization: 75%
  • Refills: not limited to 5
Oral Electrolyte Replacement Fluid
  • Refill-too-soon utilization: 75%
  • Refills: not limited to 5
Spring-powered Device for Lancets
  • Quantity: 2 units maximum per rolling year
  • Refills: not limited to 5

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.