Prescribed Drugs Provider Manual - Iowa Department of Human ...

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage93DateAugust 1, 2013Under the VFC program, all providers are required to follow the most currentRecommended Immunization Schedule from the Advisory Committee onImmunization Practices (ACIP). The following vaccines may be ordered underthe VFC program:♦ DTaP♦ DTaP/Hep B/IPV(Pediarix)♦ DTaP/IPV/Hib (Pentacel)♦ DTaP/IPV (Kinray)♦ DT (pediatric)♦ Td preservative free♦ Tdap♦ Hib♦ Hib/Hep B♦ Hepatitis A♦ Hepatitis B♦ HPV (Gardasil)♦ Influenza♦ MMR♦ MMR/V (ProQuad)♦ Meningococcal conjugate (Menactra)♦ Pneumococcal conjugate (Prevnar)♦ Polio♦ Rotavirus♦ VaricellaFor more information, see the Iowa Department of Public Health web page:http://www.idph.state.ia.us/ImmTB/Immunization.aspx?prog=Imm&pg=VfcAs a result, pharmacists are not reimbursed for providing these vaccineswhen administered by the practitioner. EXCEPTIONS: Payment forimmunizations administered to these persons will continue:♦ Medicaid members who are enrolled in an HMO that has contracted toprovide specific Medicaid services.♦ When Medicare makes payment, the deductibles, coinsurance, and anyMedicaid-covered services beyond the scope of Medicare are consideredfor coverage for Medicaid members who are dually eligible for Medicaidand Medicare.♦ Pharmacies enrolled in the Vaccines for Children (VFC) Program throughthe Iowa Department of Public Health may administer influenza vaccinesfor children age 18 and under. Pharmacies will be paid for administrationof influenza vaccines when the vaccine is covered under the VFC Program.Pharmacists can be reimbursed for vaccines for patients in an institutionalsetting where facility staff administer the vaccine.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage94DateAugust 1, 2013E. BILLING SYSTEMIowa Medicaid Enterprise provides for on-line, real-time processing of Medicaidpharmacy claims. Through electronic submission, you are able to submit claimsmore accurately. You also receive your Medicaid payments sooner than if yousubmitted paper claims.Point-of-sale (POS) transactions are handled by the Iowa Medicaid EnterprisePharmacy Point of Sale (POS) Unit. POS will handle the overrides for prospectivedrug utilization review edits such as high dose, therapeutic duplication, refill toosoon, excessive days supply, dose consolidation, duplicate claim, orimmunosuppressant drugs.Providers that wish to exercise the point of sale billing option must complete theIowa DHS Point of Sale Agreement. Please visit www.iowamedicaidpos.com tocomplete this agreement. You may call the (Point of Sale) POS Helpdesk at877-463-7671 or locally at 515-256-4608.1. Point of Sale Claim SubmissionFor point-of-sale (POS) submitters, refer to your POS Payer Sheet for claimsubmission instructions explanation of the data fields for the electronic billingformat. (To view the instruction on line, click here.)The Iowa Medicaid Enterprise eliminated the procedure of paying pharmacyclaims and then billing the primary insurance company on behalf of themembers (“pay and chase”) effective January 16, 2007, except for childrenunder age 21 and pregnant women.♦ For members under age 21, pharmacy claims may be processedthrough Pharmacy Point of Sale System with Iowa Medicaid as theprimary insurer.♦ For members who are pregnant, bill claims through the PharmacyPoint of Sale System with Iowa Medicaid as the primary insurer. To get a$0.00 copayment:• Enter code “2” (medical certification) in the prior authorization typecode field (NCPDP field 461-EU), and• Enter code “4” in the Prior Auth Number Submitted (NCPDP field462-EV).
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