The final rule CMS-0055-F from the U.S. Department of Health and Human Services requires the reporting of the NCPDP Quantity Prescribed (460-ET) field for all Schedule II drugs on pharmacy claims as of September 21, 2020.
On November 21, 2019, the Pharmacy Help Desk (800-392-8030) began including additional menu options. You must listen to the entire opening message before selecting an option. This is to ensure the correct option is chosen. The new message and options are listed below. If no option is selected from the main menu, the main menu message will replay again.
Pharmacy message:
MO HealthNet will reimburse any medication for a MO HealthNet participant dispensed within the eligibility period shown on a MO HealthNet Presumptive Eligibility Authorization (PE-3) form.
MO HealthNet will also reimburse any medication for a MO HealthNet participant dispensed within the eligibility period shown on a Show Me Healthy Babies Presumptive Eligibility (SMHB-PE) Authorization form.
On August 19, 2018, the MO HealthNet Division (MHD) will implement a maximum daily quantity edit. This quantity limit is based upon the maximum number of units of the drug allowed per day as determined by the MHD or First Databank’s (FDB) MedKnowledge. The correct day's supply must be submitted on drug claims based on the quantity dispensed and the directions as written by the prescriber. Claims submitted for a quantity above the maximum daily units will deny.
The MO HealthNet Presumptive Eligibility Authorization (PE-3) form and the Show Me Healthy Babies Presumptive Eligibility (SMHB-PE) Authorization form serve as proof of presumptive eligibility. Pharmacy providers should check the dates of eligibility on the authorization form to determine if the presumptive eligibility period is active. Pharmacy providers should make a photocopy of the form and maintain the copy in the pharmacy files for documentation of eligibility.
Providers must charge and collect the shared pharmacy dispensing fee amount required to be paid by MO HealthNet participants. Providers may not deny or reduce services solely on the basis of the participant's inability to pay the fee when charged. A participant's inability to pay a required amount shall in no way extinguish the participant's liability to pay the amount. The amount is a legal debt and is due to the provider.
Providers must bill the correct quantities for medications dispensed to participants in the outpatient hospital setting. Section 15.24.E of the Hospital Provider Manual states the quantity to be billed for injectables and other types of medications dispensed to MHD participants must be calculated as follows:
Pharmacies are required to document the offer to counsel MO HealthNet participants on their prescription medications. The pharmacy must obtain the signature of the participant or his/her representative for each prescription received, with the exception of participants living in long-term care facilities, i.e. nursing facilities, intermediate care facilities/mentally retarded (ICF/MR) and/or psychiatric residential treatment facilities (PRTF).
