Medical, Dental & Pharmacy
- Medical
- Ambulatory Surgical Services
- Children's Services
- Chiropractic
- Clinic Services
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- Early Intensive Development and Behavioral Intervention (EIDBI)
- Equipment and Supplies
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- Laboratory/Pathology, Radiology, and Diagnostic Services
- Language Interpreter Services
- Long-Term Care
- Medication Reconciliation
- Mental Health Services
- Optical Services
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- Physician and Professional Services
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- School-Based Community Services
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- Transportation
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- Dental
- Pharmacy
Long-Term Care Facilities (LTCFs) Billing Procedures for Pharmacies
Medicare Part A Members
Patients that qualify for Medicare Part A during some or all of their stay in an LTCF or group home are not to be billed for any supplies and medications that they require during their stay under Part A guidelines. PrimeWest Health is not to be billed for any of these medications or services, either. The facility is responsible to provide all prescribed medications and therapies (this comes out of the per diem payment). It is strictly prohibited to require patients to bring their own medications from home to use during their Medicare Part A stay or to deny therapies that are medically necessary. Medications sent with the patient from the hospital upon discharge may be used (if reordered by the prescriber) as long as the patient has no objections. Nothing prohibits the home or the pharmacy from requesting therapeutic alternatives from the prescriber that are therapeutically equivalent but perhaps more cost-effective. In the end, the prescriber has the final authority as to what is medically necessary to treat the patient during his/her stay under Part A.
Pharmacies that provide services to nursing home patients should be familiar with the following guidelines:
- Claims should be billed per pharmacy policy. Dispensing fees will not be paid for each partial fill.
- Seven-day unit packages should be logged and billed no more than once per month
- In no event may the OTC product be priced higher than the shelf price
- Items that are normally supplied by the nursing home on a per diem basis, such as test strips and syringes, should not be billed to PrimeWest Health. Unique dispensing methods such as tray changes every 2 days or every 7 days do not justify additional fees. One fee per month is reimbursable even if the product is delivered to a nursing home one tablet at a time.
- Items related to personal hygiene and over-the-counter medications used on an as-needed basis should be covered by the nursing home per diem and not PrimeWest Health.
Prescribed Medications Not Covered Under the PrimeWest Health Prescription Benefit
Federal law requires that LTCFs provide residents with all prescribed medications that are not covered by the outpatient pharmacy program. These drugs are part of an LTCF’s per diem and are reported in a cost report to DHS. Nothing prohibits the LTCF or pharmacy from requesting a formulary product from the prescriber.
Long-Term Care Facility (LTCF) Lost or Damaged Medication
PrimeWest Health should NOT be billed twice if medication sent to the LTCF is lost, stolen, destroyed, or damaged. If the pharmacy loses the medication before delivering it to the facility, the pharmacy must send a replacement supply to the facility at their expense. If the loss occurs after it is delivered, the pharmacy can send a replacement supply that MUST be billed to the facility not to PrimeWest Health or the member.
Emergency Kit Medication Billing Policy
If an LTCF uses a dose of medication from an emergency kit, that dose may be billed separately to PrimeWest Health only if certain conditions are met:
- If only one total dose is given, the pharmacy supplying the dose may bill PrimeWest Health for a single dose; or
- If the dose is the first in a series of doses, it must be billed to PrimeWest Health together with subsequent doses. For example, if the order is for Ceftriaxone 1gm IM once, and the dose is taken from the emergency kit, the pharmacy may replace that dose and bill PrimeWest Health. If the order is for Ceftriaxone 1gm IM once daily for 7 days, and the first dose is taken from the emergency kit, the pharmacy should not bill PrimeWest Health for one dose to replace what was taken from the kit and six doses for the remainder of the supply. All seven doses must be billed as one prescription.
Solutions, Irrigations, and Supplies for Long-Term Care Facilities (LTCFs)
PrimeWest Health does not pay for solutions, irrigations, or supplies used in LTCFs for respiratory or wound care. This includes normal saline for irrigation, sterile water for irrigation, compounded antibiotic irrigation solutions, saline for inhalation, or trach care, etc. These are all part of the per diem paid to the LTCF. Pharmacies should not bill these products as drugs when the member is in the facility.
“Extra” Medication Supplies for Multiple Sites
If a F&C/MinnesotaCare/MSC+/SNBC/PrimeWest Senior Health Complete/Prime Health Complete member, especially a resident of a nursing facility or group home, needs a small quantity of medication for passes, school, a job, or day programs, the pharmacy cannot bill PrimeWest Health separately. For example, if a member receives Metformin 500 mg twice daily, the pharmacy cannot separately bill for 60 tablets for use in a group home and 30 tablets for use elsewhere. The total 90 tablets must be billed at one time to PrimeWest Health. The pharmacy can package the medication in any manner consistent with State and Federal pharmacy laws and regulations. In this example, that might mean packaging 60 tablets in a unit dose container and 30 in a vial. However, packaging the prescription in two containers does not entitle the pharmacy to two dispensing fees.
Supply Requirements
LTC pharmacies and LTCFs are subject to the same days’ supply limitations as all other PrimeWest Health-enrolled pharmacies.
“Catch-Up” Supplies of Medication
Current Minnesota Statutes and Rules prohibit billing for “catch-up” supplies. Some pharmacies that service nursing facilities dispense small “catch-up” supplies of medications if the home runs out before the end of a billing cycle.
For example, the pharmacy dispensed a 31-day supply only to have the facility call 25 days later indicating that it is out of the drug. The pharmacy then dispenses a six-day supply and bills PrimeWest Health. A few days later, the pharmacy bills PrimeWest Health for another 31-day supply in order to get back on schedule. This is prohibited as only one dispensing fee is authorized per 31-day billing cycle.
OTC Drugs
During the course of a Medicare or Medicaid stay, Federal law requires LTCFs to provide residents with medically necessary OTC drugs used on an occasional or as-needed basis. These drugs are part of the LTCF’s per diem and are reported in a cost report to PrimeWest Health.
OTC drugs prescribed for a specific resident for scheduled use should be submitted separately to PrimeWest Health for reimbursement.
Emergency Medication Usage
A transition process is implemented for Medicare beneficiaries currently living in LTCFs or receiving medications from LTC pharmacies. This process allows for medications that are not on the Part D formulary but are required in the medical management for beneficiaries. In the event a PrimeWest Health member who resides in an LTCF requires urgent medication use that is not on formulary, the following options are available to better serve that member:
- Contact the prescriber with a therapeutic substitution available on formulary (preferred method)
- Call the MedImpact Help Desk at 1-800-788-2949 (toll free) for a manual system override
- Have the prescriber submit a formulary exception request
Safety Recall Notifications
- Members taking medications affected by Class I recalls for safety reasons will be identified through claims data and mailed a notice of the recommended action to be taken. These notices may contain other covered formulary options that are comparable to the affected recalled medication. The prescribing health care provider will also be notified through United States (U.S.) mail with similar information. These notices will be sent as expeditiously as possible.
- Members taking medications affected by Class II recalls or voluntary drug withdrawals for safety reasons will be identified through claims data and mailed a notice of the recommended action to be taken. These notices may contain other covered formulary options that are comparable to the affected recalled medication. The prescribing health care provider will also be notified through U.S. mail with similar information. These notices will be sent within 30 days of the recall notification by the FDA or manufacturer.
- Medications subject to a Class I recall are removed from the First DataBank libraries and are not eligible for payment.
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