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Library: Policy

317:30-5-78.1. Special billing procedures

Revised 9-14-18

(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 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) PartiallyBfilled 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.

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