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Fee-for-Service Pharmacy Consolidation
Frequently Asked Questions
PDF (106 KB)
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Q1. |
How do I submit claims for a newborn who does not yet have a
BadgerCare Plus member ID? |
A1.
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A newborn’s fee-for-service member ID is generally in the Wisconsin
Enrollment Verification System within three to five days of the
child’s birth. You can check for the newborn’s own fee-for-service
member ID using Automated Voice Response (AVR) system at (800)
947-3544 or (608) 221-4247.
If the newborn’s number is not available for a specific date of
service (DOS), verify the mother’s eligibility using the AVR system.
A newborn whose mother is eligible on the DOS is also eligible under
the BadgerCare Plus continuously eligible newborn policy.
Claims Submission
If the newborn’s member ID is on file, submit the claims through
the real-time point of sale (POS) system. If not, the provider may
hold the claim until the newborn’s number is on file and submit the
claim through POS. The provider may also submit the claim using the
emergency supply policy. For more information on the emergency
supply policy, refer to the February 2007 Wisconsin Medicaid and
BadgerCare Update (2007-14), titled “Emergency
Medication Dispensing,” which can be found on the Medicaid Web
site at dhfs.wisconsin.gov/medicaid/updates/index.htm. For
more information on the newborn reporting policy, see the June 2003
Update (2003-29), titled “Wisconsin
Medicaid will no longer reimburse claims submitted for newborns
under the mother’s identification number,” which can be found on
the Medicaid Web site at dhfs.wisconsin.gov/medicaid/all_provider/archives.htm.
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Q2. |
Does grandfathering apply to brand medically necessary mental
health drugs? |
A2.
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Grandfathering applies only to non-preferred mental health drugs.
For fee-for-service members taking a brand name mental health drug
for which there is a generic, grandfathering does not apply. |
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Q3. |
Where do I send my pharmacy grievance or appeal? |
A3.
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If your grievance or appeal has a DOS prior to February 1, 2008,
it should be sent to your HMO. If your grievance or appeal has a DOS
on or after February 1, 2008, send it to BadgerCare Plus
fee-for-service, by contacting member services at (800) 362-3002. |
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Q4. |
How do I submit claims for a
physician-administered drug? |
A4.
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If providers are currently submitting claims for a
physician-administered drug with a National Drug Code (NDC), submit
the claim with an NDC to fee-for-service Standard Plan via the
real-time POS system or on paper using the
Noncompound Drug Claim form, HCF 13072, found on the Medicaid
Web site at dhfs.wisconsin.gov/medicaid4/forms/index.htm. If
currently submitting claims for a physician-administered drug with a
Current Procedural Terminology (CPT) or Healthcare Common Procedure
Coding System (HCPCS) procedure code, continue submitting the claim
with the procedure code to the HMO. |
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Q5. |
How do I submit claims for home
infusion drugs and supplies? |
A5.
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If you currently submit claims for home infusion drugs and supplies
using HCPCS or CPT procedure codes, continue using procedure codes
and submit the claims to the HMO. If you currently submit claims for
home infusion drugs using an NDC and for supplies using procedure
codes, submit the drug (NDC) claim to fee-for-service Standard Plan
using the POS system or on paper and the supplies (HCPCS or CPT
codes) to the HMO. |
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Q6. |
What are the helpline contacts for more information
on the pharmacy consolidation? |
A6.
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Provider Services — (800) 947-9627 or (608) 221-9883.
| Hours: |
8:30 a.m. – 4:30 p.m. Monday, Wednesday-Friday
9:30 a.m. – 4:30 p.m. Tuesday
9:00 a.m. – 4:00 p.m. Saturday-Sunday (February 2, 3, 9,
10, 2008, and April 5, 6, 12, 13, 2008, ONLY) |
Member Services — (800) 362-3002 or (608) 221-5720
| Hours: |
7:30 a.m. – 5:00 p.m., Monday-Friday
9:00 a.m. – 4:00 p.m. Saturday-Sunday (February 2, 3, 9,
10, 2008, and April 5, 6, 12, 13, 2008, ONLY) |
STAT-PA — (800) 947-1197 or (608) 221-2096
| Hours: |
8:00 a.m. - 11:45 p.m., Available via touch tone phone
seven days a week. |
STAT-PA Help Desk — (800) 947-1197, press "0" or (608) 221-2096,
press "0".
| Hours: |
8:00 a.m. – 6:00 p.m., Monday-Friday |
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Q7. |
Where can I find additional BadgerCare Plus pharmacy
consolidation information on the Web? |
A7.
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Refer to the following Web sites for additional information about
pharmacy consolidation:
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Q8. |
Will a child still be able to get Synagis treatment if he or she
turns 2 years old after February 1, 2008? |
A8.
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Yes, providers should submit claims for Synagis for a child who
turns 2 years old during the Respiratory syncytial virus (RSV)
season using the paper
Noncompound Drug Claim form, found at the Medicaid Web site at
dhfs.wisconsin.gov/medicaid4/forms/index.htm. The claim
should be submitted with the
Pharmacy Special Handling Request form, HCF 13074 which can be
found on the Medicaid Web site at dhfs.wisconsin.gov/medicaid/forms/index.htm.
The special handling claim form should include information on the
medical necessity for continuing Synagis.
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Q9. |
How do I obtain a prior authorization (PA) for a
drug whose labeler does not have a Centers for Medicare and Medicaid
Services signed manufacturer rebate agreement? |
A9.
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Wisconsin Medicaid requires paper PA for certain drug categories
produced by manufacturers who signed drug rebate agreements with the
CMS in order to determine medical necessity. A
list
of these drug categories requiring PA can be found in the
Covered Services and Reimbursement section of the Pharmacy handbook.
Request PA for covered rebated drug categories by submitting a
paper Prior Authorization Request Form (PA/RF), HCF 11018 and a
Prior Authorization/Drug Attachment (PA/DGA) for legend drugs.
The prescription documentation must be valid on the grant date of
the PA request. Refer to
Appendix 8,
Appendix 10, and
Appendix 11 of the Prior Authorization section of the Pharmacy
Handbook for a sample PA/RF and for PA/DGA forms for photocopying.
Covered Non-Rebated Drugs That Require Paper Prior
Authorization Requests
Certain drugs require paper PA because their manufacturer did
not sign a rebate agreement with HCFA. To request PA for these
drugs, providers must submit a paper PA/RF, a PA/DGA for legend
drugs, and a statement of medical necessity and cost effectiveness
for these specific brand drugs.
Documentation of Medical Necessity and Cost Effectiveness
The statement of medical necessity required for PA requests for
non-rebated drugs must include the prescriber’s conclusion that
the non-rebated drug is the only available and medically
appropriate product for treating the recipient, and the details of
the recipient’s clinical experience which led to that conclusion.
The documentation of the recipient’s clinical experience may
include:
- A copy of the recipient’s medical record documenting the
dates and clinical details of therapeutic failures and the
specific companies and generic products involved.
- A copy of the documentation provided by the prescriber
about the recipient’s experience of therapeutic failure with a
generic product of one or more manufacturers.
- A prescriber’s documentation of the recipient’s blood
levels showing that the blood levels were substantially lower
when using a generic drug than when using the brand name drug.
- A copy of the recipient’s records showing that other drug
products within the same therapeutic class of drugs have been
ruled out because previous clinical trials with that recipient
produced ineffective or unsafe results (e.g., allergic
response).
- A prescriber’s documentation showing how some unique
characteristic (e.g., dosage form, pharmaceutical formulation,
therapeutic indication) of the drug prescribed is essential to
assure the recipient receives specific medically necessary and
cost effective treatment.
The following sample prescriber statements are not sufficient
by themselves as documentation of medical necessity and cost
effectiveness:
- "The recipient becomes ill on the generic drug."
- "The recipient is convinced that only the brand name drug
will work for him."
- "Only the brand name drug is effective."
- "The recipient insists that the generic drug is
ineffective."
- "It is my professional opinion that this recipient requires the
brand name drug for his condition. Generic versions are unacceptable
in the patient’s treatment as they provide no benefit to him."
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