(a) To receive payment from the Health and Human Services
Commission (Commission), the provider must submit a pharmacy claim
through the electronic adjudication system. A separate entry is submitted
for each prescription or refill. For the original dispensing and each
subsequent refill, the provider indicates on the corresponding pharmacy
claim submitted to the Commission the usual and customary price, the
purchasing method, and the National Drug Code (NDC). Claims received
over 90 days after the date of service are rejected. For claims on
behalf of an individual who has applied for Medicaid coverage but
has not yet been assigned a recipient number on the date of service,
the filing period does not commence until the date the individual
has been assigned a number. The requirements in §354.1863 of
this subchapter (relating to Prescription Requirements) are also waived
for retroactive claims. The provider must ensure, however, that a
prescription submitted for a prior eligibility period conformed to
Texas State Board of Pharmacy and Commission regulations on the date
of service, or a claim cannot be submitted.
(b) Providers must dispense the quantity prescribed
or ordered by the prescriber except as limited by the policies and
procedures described in the Commission's pharmacy provider procedure
manual, or as allowed by §354.1868 of this subchapter (relating
to Exceptions in Disasters). Where the actual quantity dispensed deviates
from the prescribed quantity, the provider must bill for the amount
actually dispensed. The quantity of drugs must be entered in the metric
decimal quantity field. The quantity shown as the metric decimal quantity
unit must be calculated after referencing the pricing unit shown in
the Texas Drug Code Index.
(c) If all necessary information is not supplied, a
claim will not be processed or paid.
(d) The provider must submit claims as the prescription
is dispensed through the on-line system. Providers who supply a large
volume of medications to nursing facility recipients may submit these
claims through their data transmission company after the point of
sale.
(e) Overcharged prescription claims are not denied.
The Commission pays the appropriate drug cost. The appropriate drug
cost is the acquisition cost, as determined by the Commission or other
source in accordance with §355.8541 of this title (relating to
Legend and Nonlegend Medications), plus the professional dispensing
fee. The amount claimed and the amount paid are shown on the payment
register.
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Source Note: The provisions of this §354.1901 adopted to be effective November 16, 1987, 12 TexReg 3553; amended to be effective February 27, 1989, 14 TexReg 630; amended to be effective July 1, 1993, 18 TexReg 1584; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective October 27, 1997, 22 TexReg 10317; amended to be effective October 8, 1998, 23 TexReg 9982; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4562; amended to be effective June 19, 2003, 28 TexReg 4541; amended to be effective January 14, 2013, 37 TexReg8462; amended to be effective May 15, 2016, 41 TexReg 3291 |