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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsPage4DateAugust 1, 2013PageE. BILLING SYSTEM ...................................................................................... 941. Point of Sale Claim Submission ............................................................ 94a. Claims Rejected Due to Other Insurance Coverage .......................... 95b. Correction of Insurance Information .............................................. 962. Claiming Payment for Retroactively Eligible Member ............................... 963. Claim Attachment Control, Form 470-3969 ............................................ 974. Paper Claim Submission ...................................................................... 97F. EDITS AND SPECIAL BILLING INFORMATION .............................................. 1051. Claims for Deceased Members ........................................................... 1052. Common Billing Errors ...................................................................... 1053. Compounded Prescriptions ................................................................ 1074. Coverage of Non-Drug Products ......................................................... 1075. Date of Birth Verification ................................................................... 1096. Override Codes ................................................................................ 1107. Proper Reporting of NDCs ................................................................. 1108. Prospective Drug Utilization Review (Pro-DUR)..................................... 111a. Age Edits ................................................................................. 113b. Cost Effectiveness Edit .............................................................. 115c. Dosage Form Edits .................................................................... 116d. Excessive Days Supply .............................................................. 116e. High-Dollar Claims .................................................................... 116f. Refill Too Soon ......................................................................... 117g. Step Therapy Edits.................................................................... 117h. Tablet Splitting ......................................................................... 117i. Therapeutic Duplication ............................................................. 1189. Status Change for Preferred Brand Name Drugs ................................... 11810. Travel or Vacation Supplies of Medication ............................................ 11811. 340B Drug Pricing Program ............................................................... 119a. Covered Entity (CE) .................................................................. 119b. Iowa Medicaid Billing/Reimbursement for CE Outpatient In-HousePharmacy or Contracted Pharmacy .............................................. 12012. Interpreter Services ......................................................................... 120a. Documentation of the Service ..................................................... 121b. Qualifications ........................................................................... 121G. REMITTANCE ADVICE AND FIELD DESCRIPTIONS ........................................ 1221. Remittance Advice Explanation .......................................................... 1222. Remittance Advice Field Descriptions .................................................. 123