5101:3-9-02 Pharmacy services: medical supplies and durable medical equipment.

(A) Eligible pharmacies in the Ohio medicaid program may bill for medical supplies and durable medical equipment in accordance with Chapter 5101:3-10 of the Administrative Code, with the following stipulations:

(1) The provider must apply to the Ohio department of medicaid (ODM) to be eligible to dispense medical supplies/durable medical equipment.

(2) All products require a prescription written by a practitioner authorized to prescribe. The prescription must be obtained by and kept on file at the pharmacy.

(3) The provider must use the same medicaid provider number as when billing for pharmaceuticals.

(4) The provider must be licensed, registered, or exempt from licensure or registration under Chapter 4761. of the Revised Code to bill for home medical equipment that is subject to regulation under Chapter 4752. of the Revised Code.

(B) Invoices submitted for medical supplies/durable medical equipment must be billed on the appropriate invoice designated by ODM for those services.

(C) Medical supplies, durable medical equipment, prosthetic, and orthotic devices may be billed by pharmacy providers in accordance with Chapter 5101:3-10 of the Administrative Code.

(D) Only eligible providers of pharmacy services as described in rule 5101:3-9-01 of the Administrative Code are eligible to bill for the medical supplies listed in the appendix to this rule, except as specified in paragraph (G) of this rule. Eligible providers of pharmacy services may bill for these items without applying to ODM to be eligible to dispense medical supplies/durable medical equipment as described in Chapter 5101:3-10 of the Administrative Code.

(E) The quantity billed should be equal to the number of items dispensed (e.g., the quantity of test strips billed should be the number of individual test strips, not the number of boxes). The table in the appendix to this rule includes five columns to indicate supply item coverage and reimbursement.

(1) Item description. This column describes the supply item.

(2) Medicaid coverage status. This column has one of two possible indicators for each item. "Y" indicates the item is covered by medicaid for all consumers and may be billed directly to ODM by the provider. "H" indicates that the item may be billed directly to ODM only for consumers who reside in their personal residence. For consumers residing in a nursing facility (NF) or intermediate care facility for the mentally retarded (ICF-MR) as defined in section 5111.20 of the Revised Code, the supply is the responsibility of the NF or ICF-MR and reimbursed to the NF or ICF-MR through the facility per diem payment.

(3) Covered for dual eligible. This column indicates whether the supply is covered under the medicaid program for a consumer who is a dual eligible as defined in rule 5101:3-1-05 of the Administrative Code. "Y" indicates the supply is covered for a dual eligible. "N" indicates the supply is not covered for a dual eligible.

(4) Maximum units. This column indicates the largest number of units of the supply that may be dispensed within the time period indicated. Claims submitted that exceed the maximum units shall be denied. Denials may be overridden by ODM or its designee in cases where medical necessity has been determined through prior authorization obtained by the prescriber from the ODM point-of-sale vendor.

(5) Reimbursement. This column indicates the medicaid maximum reimbursement per item as defined in rule 5101:3-1-60 of the Administrative Code. Supplies with "*" in this column indicate that reimbursement will be calculated in accordance with paragraph (B)(2) of rule 5101:3-9-05 of the Administrative Code.

(F) The supplies listed in the appendix to this rule should be billed through the pharmacy point of sale claims system using the national drug code (NDC) on the container from which the product was dispensed.

(1) Reimbursement shall be the lesser of the submitted charge or the calculated allowable. The calculated allowable is the medicaid maximum reimbursement as described in paragraph (E)(5) of this rule.

(2) Prior authorization may be requested by the prescriber or a member of the prescribing provider's staff if there is medical necessity for quantities above those stated in the appendix to this rule.

(G) Exceptions to pharmacy billing requirement.

(1) Contraceptive supplies listed in the appendix to this rule may be billed by both pharmacy providers and providers eligible to bill in accordance with rule 5101:3-10-01 of the Administrative Code. Pharmacy providers shall bill these supplies in accordance with paragraph (F) of this rule.

(2) Supplies billed to medicare as the primary payer and crossed over to medicaid using the medicare crossover process described in paragraph (B) of rule 5101:3-1-05 of the Administrative Code may be billed by any provider eligible for the medicare crossover process.

(H) Preferred diabetic blood testing supplies

(1) Products from the following manufacturers have been selected as preferred diabetic blood testing supplies:

(a) "Abbott Diabetes Care"

(b) "Nipro Diagnostics"

(2) Products from manufacturers or distributers that have not been selected as preferred require prior authorization.

(a) Only the prescribing provider or a member of the prescribing provider's staff may request prior authorization.

(b) The prescriber must document medical necessity for the non-preferred product and why a preferred product cannot be used.

(c) When a request for prior authorization is denied, the consumer will be informed in writing of the denial and the right to a state hearing.

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Effective: 07/01/2013
R.C. 119.032 review dates: 04/16/2013 and 07/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , section 309.30.30 of Am. Sub. H.B. 153, 129th G. A.
Prior Effective Dates: 4/7/77, 12/21/77, 5/9/86, 10/1/97, 8/30/01, 7/1/06, 2/1/10, 10/1/11