Rule 5160-9-02 | 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 5160-10 of the Administrative Code, with the following stipulations:
(1) The provider must:
(a) Apply to, and be approved by, the Ohio department of medicaid (ODM) to be eligible to dispense medical supplies/durable medical equipment; and
(b) Use the same medicaid provider number as when billing for pharmaceuticals; and
(c) 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.
(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.
(B) Claims submission and billing.
(1) Medical supplies/durable medical equipment is billed in the appropriate claim format designated by ODM for those services.
(2) Medical supplies, durable medical equipment, prosthetic, and orthotic devices are billed by pharmacy providers in accordance with Chapter 5160-10 of the Administrative Code.
(3) Medical supplies are billed by eligible providers of pharmacy services only, except as specified in paragraph (C) of this rule. Eligible providers of pharmacy services may bill for these items without applying to ODM for eligibility for dispensation of medical supplies/durable equipment as described in Chapter 5160-10 of the Administrative Code. The list of supplies is located on the ODM pharmacy website at https://pharmacy.medicaid.ohio.gov.
(4) Quantities billed should equal the number of items dispensed (e.g., the quantity of test strips billed should equal the number of individual test strips, not the number of boxes).
(5) The medical supplies document "Pharmacy benefits: medical supplies and durable medical equipment products" is located on the ODM pharmacy website and includes five columns indicating supply item coverage and payments. The supplies in the document are billed through the pharmacy point of sale claims system using the national drug code (NDC) on the container from which the product was dispensed.
(a) Payment is the lesser of the submitted charge or the calculated allowable. The calculated allowable is the medicaid maximum payment.
(b) The calculated allowable is the medicaid maximum payment plus the professional dispensing fee applicable to the provider as described in paragraph (E)(1)(b) of rule 5160-9-05 of the Administrative Code.
(C) 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 5160-10-01 of the Administrative Code. Pharmacy provider should bill through the pharmacy point of sale claims system using the NDC on the container from which the product was dispensed.
(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 5160-1-05 of the Administrative Code may be billed by any provider eligible for the medicare crossover process.
(D) Preferred medical supplies.
(1) Selected products from the medical supply categories included in the appendix of this rule are designated as preferred brands, as specified on the ODM website at https://pharmacy.medicaid.ohio.gov.
(2) Products that are not designated as preferred supplies require prior authorization.
(a) Only the prescribing provider or a member of the prescribing provider's staff may request prior authorization.
(b) The prescriber should document medical necessity for the non-preferred brand and provide the reason why preferred brand cannot be used.
(c) When a request for prior authorization is denied, the recipient is informed in writing of the denial as well as informed of the right to appeal the denial.
Last updated February 16, 2024 at 8:11 AM
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