SECTION 354.1901. Pharmacy Claims

(a) To receive payment from the Health and Human Services Commission (Commission), the provider must submit a pharmacy claim through the electronic adjudication system. A separate entry is submitted for each prescription or refill. For the original dispensing and each subsequent refill, the provider indicates on the corresponding pharmacy claim submitted to the Commission the usual and customary price, the purchasing method, and the National Drug Code (NDC). Claims received over 90 days after the date of service are rejected. For claims on behalf of an individual who has applied for Medicaid coverage but has not yet been assigned a recipient number on the date of service, the filing period does not commence until the date the individual has been assigned a number. The requirements in §354.1863 of this subchapter (relating to Prescription Requirements) are also waived for retroactive claims. The provider must ensure, however, that a prescription submitted for a prior eligibility period conformed to Texas State Board of Pharmacy and Commission regulations on the date of service, or a claim cannot be submitted.

(b) Providers must dispense the quantity prescribed or ordered by the prescriber except as limited by the policies and procedures described in the Commission's pharmacy provider procedure manual, or as allowed by §354.1868 of this subchapter (relating to Exceptions in Disasters). Where the actual quantity dispensed deviates from the prescribed quantity, the provider must bill for the amount actually dispensed. The quantity of drugs must be entered in the metric decimal quantity field. The quantity shown as the metric decimal quantity unit must be calculated after referencing the pricing unit shown in the Texas Drug Code Index.

(c) If all necessary information is not supplied, a claim will not be processed or paid.

(d) The provider must submit claims as the prescription is dispensed through the on-line system. Providers who supply a large volume of medications to nursing facility recipients may submit these claims through their data transmission company after the point of sale.

(e) Overcharged prescription claims are not denied. The Commission pays the appropriate drug cost. The appropriate drug cost is the acquisition cost, as determined by the Commission or other source in accordance with §355.8541 of this title (relating to Legend and Nonlegend Medications), plus the professional dispensing fee. The amount claimed and the amount paid are shown on the payment register.

Source Note: The provisions of this §354.1901 adopted to be effective November 16, 1987, 12 TexReg 3553; amended to be effective February 27, 1989, 14 TexReg 630; amended to be effective July 1, 1993, 18 TexReg 1584; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective October 27, 1997, 22 TexReg 10317; amended to be effective October 8, 1998, 23 TexReg 9982; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4562; amended to be effective June 19, 2003, 28 TexReg 4541; amended to be effective January 14, 2013, 37 TexReg8462; amended to be effective May 15, 2016, 41 TexReg 3291