Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-78.1 - Special billing procedures

Current through Vol. 41, No. 20, July 1, 2024
(a)
Antihemophiliac Factor (AHF) Products.
AHF products are sold by
				  the amount of drug (International Units of AHF) in the container. For their
				  products, regardless of the container size, the package size is always "1".
				  Therefore, pricing assumes that the "package size" actually dispensed is the
				  actual number of units dispensed. Examples: If 250 AHF units are dispensed and
				  multiplied by a unit cost of $.25, the allowable cost would be $62.50. Metric
				  Quantity is shown as 250; if 500 AHF units are dispensed and multiplied by a
				  unit cost of $.25, the allowable would be $125.00. Metric Quantity is shown as
				  500.
(b)
Compound and
				  intravenous drugs.
Prescriptions claims for compound and Intravenous
				  (IV) drugs are billed and reimbursed using the NDC number and quantity for each
				  compensable ingredient in the compound or IV, up to 25 ingredients. Ingredients
				  without an NDC number are not compensable. A dispensing fee as described in OAC
				  317:30-5-78(c)
				  is added to the total ingredient cost.
(c)
Coordination of benefits.
Pharmacies must pursue all third party resources before filing a claim with the
				  OHCA as set out in State Fiscal Administration, 42 Code of Federal Regulation,
				  Sec. 433.139.
(d)
Over-the-counter drugs.
Payment for covered over-the-counter
				  medication is made according to the reimbursement methodology in OAC
				  317:30-5-78(d).
(e)
Individuals eligible for Part B of
				  Medicare.
Payment is made utilizing the SoonerCare allowable for
				  comparable services. The appropriate Durable Medical Equipment Regional Carrier
				  must be billed prior to billing OHCA for all Medicare compensable drugs. Part B
				  crossover claims cannot be submitted through the pharmacy point of sale system
				  and must be submitted using the CMS 1500 form or electronic
				  equivalent.
(f)
Claims for
				  prescriptions which are not picked up.
A prescription for a member which
				  has been submitted to and approved for payment by OHCA which has not been
				  received by the member within fifteen (15) days of the date of service must be
				  reversed no later than the 15th day after claim
				  submission. An electronic reversal will cause a refund to be generated to the
				  agency. Claims may also be reversed using a manual process if electronic
				  reversal is not possible. For the purpose of this Section, the date of service
				  means the date the prescription was filled.
(g)
Partially-filled
				  prescriptions.
If a member has not picked up the remainder of any
				  partially-filled prescription within fifteen (15) days of the date of service,
				  the claim must be reversed on the 15th day and a new
				  claim submitted for the quantity actually dispensed.
Added at 17 Ok Reg
					 2383, eff 6-26-00; Amended at 17 Ok Reg 3506, eff 8-31-00 (emergency); Amended
					 at 18 Ok Reg 1130, eff 5-11-01; Amended at 19 Ok Reg 2773, eff 4-24-02
					 (emergency); Amended at 19 Ok Reg 2922, eff 7-1-02 (emergency); Amended at 20
					 Ok Reg 1193, eff 5-27-03; Amended at 20 Ok Reg 1941, eff 6-26-03; Amended at 25
					 Ok Reg 2662, eff 7-25-08; Amended at 28 Ok Reg 266, eff 11-15-10 (emergency);
					 Amended at 28 Ok Reg 1448, eff 6-25-11