173-71-08 Claims.

(A) For each drug dispensed under the best Rx program, the participating pharmacy or the drug mail-order system shall submit a claim to ODA not later than thirty days after the drug is dispensed by using the designated, on-line, point-of-sale system.

(B) ODA shall inform the participating pharmacy or the drug mail-order system submitting the claim of the best Rx price as determined in accordance with rules 173-71-07 to 173-71-07.3 of the Administrative Code.

(1) The prescription number of the participant’s prescription under which the drug was dispensed to the participant;

(2) The name and NDC of the drug dispensed to the participant;

(3) The number of units of the drug dispensed to the participant;

(4) The amount the participant was charged for the drug, including the administrative fee and any professional fee;

(5) The date the drug was dispensed to the participant;

(6) The best Rx identification number of the participant;

(7) The best Rx identification number of the participating pharmacy;

(8) The usual and customary charge of the participating pharmacy for the drug dispensed to the participant; and,

(9) Any other information determined necessary by ODA to make a determination on a claim in an accurate and timely manner.

(D) Subject to section 173.803 of the Revised Code, ODA shall make a payment under the best Rx program for each complete and timely claim submitted under section 173.80 of the Revised Code for a drug included in the program that is also included in a manufacturer agreement. ODA shall make the payment for a complete and timely claim by a date that is not later than two weeks after ODA receives the claim from the participating pharmacy or the drug mail-order system.

(E) Subject to paragraph (G) of this rule, ODA shall make a determination on the amount to pay for a claim by performing the following duties:

(1) ODA shall compute the manufacturer payment amount that applies to the transaction, based on quantity of the drug dispensed and the drug’s NDC, in accordance with the provisions of division (B) of section 173.812 of the Revised Code; and,

(2) ODA shall subtract from the amount computed under paragraph (D)(1) of this rule the administrative fee amount specified in rule 173-71-07.2 of the Administrative Code.

(F) ODA may combine the claims submitted by a participating pharmacy or the drug mail-order system to make aggregate payments to the participating pharmacy or the drug mail-order system, in accordance with division (C) of section 173.801 of the Revised Code.

(G) If the total of the amounts computed under paragraph (E) of this rule for any period for which payments are due is a negative number, the participating pharmacy or the drug mail-order system that submitted the claims has been overpaid for the claims. When there is an overpayment, ODA shall take one of the following options:

(1) ODA shall reduce future payments made under section 173.831 of the Revised Code to the participating pharmacy or the drug mail-order system; or,

(2) ODA shall collect an amount from the participating pharmacy or drug mail-order system that is sufficient to reimburse ODA for the overpayment.

(H) Any manufacturer payment shall include a detailed statement identifying each claim for which a payment is being remitted and the specific amount for each claim.

(I) ODA shall not charge a participating pharmacy or the drug mail-order system for the submission of a claim under section 173.80 of the Revised Code nor the processing of a claim under section 173.801 of the Revised Code.

(J) ODA may not make a payment under section 173.801 of the Revised Code for a claim submitted under section 173.80 of the Revised Code if any of the following are the case:

(1) The claim is submitted by either a pharmacy that is not a participating pharmacy or a drug mail-order system that is not the system included in the best Rx program pursuant to section 173.78 of the Revised Code;

(2) The claim is for a drug that is not included in the program;

(3) The claim is for a drug included in the program but the drug is dispensed to an individual who is not covered by a best Rx program enrollment card; or,

(4) A person or government entity has paid the participating pharmacy or the drug mail-order system through any other prescription drug coverage program or prescription drug discount program for dispensing the drug, unless the payment is reimbursement for redeeming a coupon or is an amount directly paid by a drug manufacturer to the participating pharmacy or the drug mail-order system for dispensing drugs to residents of a long-term care facility.

Replaces: pt 5101:13-1-05

Effective: 10/04/2007

R.C. 119.032 review dates: 08/31/2011

Promulgated Under: 119.03

Statutory Authority: 173.02, 173.83

Rule Amplifies: 173.80, 173.801, 173.802, 173.803

Prior Effective Dates: 11/1/2004, 4/4/07 (Emer.), 7/5/07 (Emer.)