Managed Care Pharmacy Carve-Out-Billing Notification
Effective October 1, 2009, the MO HealthNet managed Care health plans will no longer be providing pharmacy services for their members. Pharmacy claims for all MO HealthNet Managed Care members will be processed by the MO HealthNet Fee-for Service Pharmacy Program. MO HealthNet Managed Care enrollees will present their red or white MO HealthNet card and use MO HealthNet Fee-for-Service (FFS) enrolled pharmacy providers. Existing Fee-for-Service Pharmacy Program clinical editing parameters and Preferred Drug List criteria apply for coverage of pharmacy claims.
This change will impact reimbursement for any outpatient medication dispensed in a pharmacy, physician’s office, clinic, outpatient department of a hospital, or other outpatient facilities. Any medication provided in these settings will no longer be reimbursed by the Managed Care Health Plans. These products should be billed to the MO HealthNet Fee-for-Service program using the product’s appropriate NDC code, following existing MO HealthNet policy. Pharmacy claims and claims for medications administered in a physician’s office or clinic should be submitted to the FFS pharmacy program on a pharmacy claim form using the product’s 11–digit National Drug Code (NDC).
Drugs claims submitted from outpatient hospital providers should follow the existing FFS policies requiring NDCs to be submitted for only the "Top 20" multiple source physician-administered drugs dispensed in the outpatient setting. Outpatient hospital providers submitting drug information may use either an electronic Professional or Institutional ASC X 12N 837 Health Care claim transaction or by manually entering a claim into MO HealthNet’s billing web site. Claims containing any of the identified "Top 20" multiple source physician-administered drugs must be accompanied by the exact 11-digit NDC administered to the patient plus the J-code. All other drug claims may be submitted using the most appropriate J-Code or Revenue 250 Code alone on an electronic Professional or Institutional AC X 12N 837 Health Care claim transaction or emomed.
The "Top 20" multiple source physician-administered drugs are defined by CMS.