3.1 Fee for service
Claims for Medicaid, the CSHCN Services Program, and the KHC program are submitted to the Vendor Drug Program.
3.1.1 Prescription Guidelines
A written, faxed, or electronic prescription is required with the following information:
- Person’s name
- Description of the home health supply
- Quantity to dispense (quantity per day or month)
The "Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form" is not required for home health supplies dispensed through a pharmacy.
3.1.2 Claim Submission
Claims must include the specific national drug code (NDC) for the product. Multiingredient compound claims submitted with home health supplies will reject.
3.1.3 Excessive Quantity
Claims will reject if the submitted quantity exceeds the maximum unit per filling. If the prescribed quantity is medically necessary, then pharmacy staff must attest the submitted quantity is the actual quantity prescribed by resubmitting the claim with a value of “2” ("Other override") in the “Submission Clarification Code” field (42ØDK). Refer to Appendix A for quantity limits and refill limitations. This applies to claims for blood glucose test strips, blood glucose test strips with a disposable monitor, diabetic lancets, aerosol holding chamber, spring-powered device for lancet, and blood glucose monitor (talking).
3.1.4 Prescription Limits
- Claims for traditional Medicaid do not count towards a person’s three prescription-per-month limit.
- Claims for KHC will count towards a person’s four prescription-per-month limit.
- Pharmacies are not paid a dispensing fee or delivery incentive.
- Pharmacies requiring signatures to pick up prescriptions should require a signature for people picking up home health supplies.
- The "DME Certification and Receipt Form" is not required.
3.2 Managed Care
Pharmacy claims for people enrolled in Medicaid managed care or CHIP are submitted to the managed care organization (MCO). Pharmacy staff must work with the MCO's pharmacy benefit manager to determine the billing requirements, reimbursement rates, and coverage limitations for these products. MCOs can also designate certain home health supplies as preferred.
Refer to the Pharmacy MCO Assistance Chart (PDF) for the pharmacy call center phone numbers for each MCO, or refer to the Managed Care section in the Contact chapter of this manual to contact the appropriate MCO in your area.