Pharmacy Claims

If a manufacturer disputes a claim, the rebate administration staff will contact either HHSC or the dispensing pharmacy for clarification of claims paid by HHSC, or refer the dispute to the MCO. 

If the pharmacy has made an error, and the service date of the claim is within the 90-day filing period, the pharmacy can reverse the original claim and resubmit the corrected data. If the claim is outside the 90 days, the rebate administration staff will instruct HHSC or MCO staff how to correct the claim.

Common dispute reasons include:

• Omission of a decimal point 
• The quantity claimed does not match the package size (e.g., 14.5-grams claimed and the NDC is for a 17-gram inhaler)
• Excess quantity, the result of a valid keying error, or the pharmacy billed the claim using the wrong unit of measure (e.g., entered a quantity of 300 and the price is for 30)
• Low reimbursement, the result of keying errors or billing the wrong unit of measure

Pharmacy staff should ensure the units submitted are accurate for the claim and product.  Any pharmacy eligible for discounts through the Health Resources and Services Administration 340B designation should submit claims with appropriate modifiers.