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RULE §354.1801Requirements for Participation

(a) For the purposes of this subchapter, "pharmacy provider" means a provider of outpatient pharmacy services enrolled in the Medicaid program.

(b) Any pharmacy who has a current license or registration with the Texas State Board of Pharmacy or is licensed under the laws of another state and is free from any pharmacy board restriction may apply to become a pharmacy provider. Prescribing practitioners who are authorized and licensed to practice the healing arts, as defined and limited by federal and state laws, and choose to provide their own pharmaceuticals may also apply to become pharmacy providers.

(c) Except as stated in §354.1809 of this title (relating to Termination of Participation), Chapter 352 of this title (relating to Medicaid and Children's Health Insurance Program Provider Enrollment), and Chapter 371 of this title (relating to Medicaid and Other Health and Human Services Fraud and Abuse Program Integrity), the Health and Human Services Commission (HHSC) and its designee maintain open enrollment for in-state pharmacies licensed as Class A or C by the Texas State Board of Pharmacy. Pharmacies holding any other class of pharmacy license may be subject to special application procedures.

(d) A pharmacy must be enrolled as a pharmacy provider to participate as a provider in the Children's Health Insurance Program (CHIP), the Kidney Health Care (KHC) program, or the Children with Special Health Care Needs (CSHCN) program.

(e) A pharmacy does not have to be enrolled in the Medicare program to dispense covered outpatient drugs or certain supplies as defined in §354.1042 of this title (relating to Supplies Provided by a Pharmacy) to clients enrolled in the Medicaid program.

(f) A pharmacy that fills prescriptions for Medicaid clients on behalf of an enrolled Medicaid pharmacy that submits Medicaid claims (e.g., a central fill pharmacy or a pharmacy that provides medication fulfillment services) may be required to enroll in accordance with Chapters 352 and 371 of this title and is subject to other participation requirements in this division, including §354.1807 of this division (relating to Access to Records).

(g) A pharmacy applying for enrollment as a pharmacy provider is subject to the enrollment and application requirements in Chapters 352 and 371 of this title.

(h) Claims are subject to post-payment review for compliance with state and federal laws and regulations and HHSC policy. Reimbursement paid to a pharmacy provider for claims that do not comply may be subject to recoupment of overpayment.

(i) HHSC may enter into special negotiated reimbursement arrangements with other state or local entities, such as a Department of State Health Services hospital, to maximize federal financial participation in state or locally funded programs. If a state or local entity is unwilling to participate in such an arrangement, a contract or agreement may be denied.

Source Note: The provisions of this §354.1801 adopted to be effective November 16, 1987, 12 TexReg 3553; amended to be effective August 1, 1990, 15 TexReg 3860; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; 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 December 31, 2012, 37 TexReg 9905

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