Medicaid Coverage of Co-Insurance for Medicare Part B Immunosuppressant Drugs Instructions for Billing Part B Co-Insurance

 

On March 30, the Vendor Drug Program (VDP) notified pharmacy providers about a change in reimbursement for claims submitted to Medicaid as the secondary payer after Medicare Part B had paid its share ― also called “crossover claims.” (See txvendordrug.com/news/current-news.shtml.)  This change caused some crossover claims for immunosuppressant and other Part B drugs to reject or receive a response of a $0 payment. These claims may be eligible for reimbursement.

 

Beginning April 16, pharmacies should begin submitting claims for Medicare Part B co-insurance, for those prescription drugs that are a benefit of Medicaid, directly to VDP.  This includes all secondary claims for Part B covered drugs for Qualified Medicaid Beneficiary (QBM) clients only.  If you previously submitted a claim to TMHP between January 1 and April 15, 2012, and received a rejection or a response of a $0 payment, you can resubmit those claims to TMHP after May 1.  You may submit claims only to TMHP or VDP; you may not submit to both.

 

Claims submitted to VDP must be billed with the National Drug Code (NDC), not the Healthcare Common Procedure Coding System (HCPCS) number.  The NDCs submitted must be included in the Medicaid formulary.  Pharmacies should also ensure they submit the proper fields in the “Coordination of Benefit” (COB) segment.  The COB segment must include the disposition of the claim after submission to Medicare, including any amount paid.  Please refer to the Vendor Drug payer sheets at txvendordrug.com/downloads/ for specific requirements.  If you receive a rejection when attempting to bill VDP, please call our Pharmacy Resolution Help Desk at 1-800-435-4165 for assistance.

 

Vendor Drug will reimburse up to the maximum payable amount.  If the amount paid by Medicare is greater than Vendor Drug’s payable amount, Vendor Drug will not make an additional payment.  Pharmacies may not request payment directly from Medicaid customers.