Commercial Health Insurance Claim Submission Requirement

Because Wisconsin Medicaid is payer of last resort, providers are required to exhaust other health insurance sources prior to submitting claims to Wisconsin Medicaid. Effective for claims received on and after June 9, 2005, providers are required to bill all commercial health insurance carriers prior to Wisconsin Medicaid when a recipient has verified drug coverage through commercial health insurance. This is a change from current Medicaid policy that requires commercial health insurance billing of drugs for specific carriers. As a result, Appendix 9 of the Claims Submission section of the Pharmacy Handbook is no longer valid.

Pharmacies are required to bill private HMOs, all commercial health insurance, and Medicare prior to billing Wisconsin Medicaid.

Drug Utilization Review and Pharmaceutical Care Enhancement

Effective for claims processed on and after June 9, 2005, Wisconsin Medicaid is enhancing the pharmacy real-time claims submission process in the Point-of-Sale (POS) system to allow providers to submit a response to a Drug Utilization Review (DUR) alert and a Pharmaceutical Care (PC) service in the same transaction. The enhancement was originally announced in the September 2004 Wisconsin Medicaid and BadgerCare Update (2004-78), titled "Drug Utilization Review and Pharmaceutical Care Services May Be Submitted in the Same Transaction. (PDF, 159 KB)"

When providers submit real-time noncompound drug claims or reversals with a response to a DUR alert and PC dispensing fee in the same transaction, Wisconsin Medicaid requires the following National Council for Prescription Drug Programs (NCPDP) version 5.1 fields:

NCPDP Field	NCPDP Field Name
473-7E	Drug Utilization Review/Professional Pharmacy Services (DUR/PPS) Code Counter
439-E4	Reason for Service Code
440-E5	Professional Service Code
441-E6	Result of Service Code
474-8E	DUR/PPS Level of Effort (LOE)*

*The DUR/PPS LOE is only required on PC reimbursement claim submissions.

Providers may continue to send one set of DUR fields if the 439-E4, "Reason for Service Code," field for DUR and PC are the same.

Providers are required to have NCPDP field 473-7E, "DUR/PPS Code Counter," present. Wisconsin Medicaid, BadgerCare, and SeniorCare will monitor this field for claims submitted as real-time compound or noncompound drug transactions.

For real-time compound drug claims, providers are still required to indicate a DUR/PPS LOE code that will determine the compound drug dispensing fee reimbursement. As a reminder to providers, a PC service cannot be billed for a compound drug.

Refer to Attachment 1 of this Update for a table of DUR and PC claim submission examples. Attachment 2 is a table of fields that are required for DUR and PC claim submissions.

Software Testing with Wisconsin Medicaid

Pharmacy providers may test POS system changes at any time with Wisconsin Medicaid. Providers interested in software testing should contact the Division of Health Care Financing Electronic Data Interchange (EDI) Department for a test packet. After providers receive a test packet, they may contact their software vendor to coordinate testing.

Providers should work closely with their software vendors, information technology staff, and software user guides to verify that POS claims and reversals are submitted accurately according to the Wisconsin Medicaid Companion Document to HIPAA Implementation Guide: NCPDP 5.1 (Rev. 6/9/05). This document is available on the "Electronic Data Interchange (EDI) Information" page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/. The NCPDP 5.1 Implementation Guide is available from the NCPDP Web site at www.ncpdp.org/.

Providers and their software vendors may contact the EDI Department if they are interested in testing. For more information about the EDI Department or testing, providers may contact the EDI Helpdesk by telephone at (608) 221-9036 or by e-mail at wiedi@dhfs.state.wi.us.

For More Information

Providers should refer to the revised companion document for more information on NCPDP fields. Providers may refer to the Drug Utilization Review and Pharmaceutical Care section of the Pharmacy Handbook for Wisconsin Medicaid’s policy on submitting claims with a response to a DUR alert and a PC dispensing fee.

Information Regarding Medicaid HMOs

This Update contains Medicaid fee-for-service policy and applies to providers of services to recipients on fee-for-service Medicaid only. For Medicaid HMO or managed care policy, contact the appropriate managed care organization. Wisconsin Medicaid HMOs are required to provide at least the same benefits as those provided under fee-for-service arrangements.

Attachment 1 — Drug Utilization Review and Pharmaceutical Care Claim Submission Examples
Attachment 2 — Drug Utilization Review and Pharmaceutical Care Claim Submission Requirements