WSR 21-05-043
PERMANENT RULES
HEALTH CARE AUTHORITY
[Filed February 11, 2021, 3:45 p.m., effective March 14, 2021]
Effective Date of Rule: Thirty-one days after filing.
Purpose: The agency is amending this rule to revise the signature requirement for pharmacy products dispensed and delivered directly to a medicaid client or their provider's office. The proposed rule requires either the client or the provider to sign for delivered products. The new signature requirement ensures proof of delivery for prescriptions sent to a provider's office, which decreases the potential for medicaid fraud and duplicate billing.
Citation of Rules Affected by this Order: Amending WAC 182-530-5000.
Adopted under notice filed as WSR 21-02-072 on January 5, 2021.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 1, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.
Date Adopted: February 11, 2021.
Wendy Barcus
Rules Coordinator
OTS-2176.2
AMENDATORY SECTION(Amending WSR 16-01-046, filed 12/9/15, effective 1/9/16)
WAC 182-530-5000Billing requirements—Pharmacy claim payment.
(1) When billing the medicaid agency for pharmacy services, providers must:
(a) Use the appropriate agency claim form or electronic billing specifications;
(b) Include the actual eleven-digit national drug code (NDC) number of the product dispensed from a rebate eligible manufacturer;
(c) Bill the agency using metric decimal quantities which is the National Council for Prescription Drug Programs (NCPDP) billing unit standard;
(d) Meet the general provider documentation and record retention requirements in WAC 182-502-0020; and
(e) Maintain proof of delivery receipts.
(i) When a provider delivers an item directly to the client or the client's authorized representative, the provider must be able to furnish proof of delivery, including ((signature,))the signature of either the client or the provider, the client's name, and a detailed description of the item or items delivered.
(ii) When a provider mails an item to the client, the provider must be able to furnish proof of delivery including a mail log.
(iii) When a provider uses a delivery or shipping service to deliver items, the provider must be able to furnish proof of delivery and it must:
(A) Include the delivery service tracking slip with the client's name or a reference to the client's package or packages; the delivery service package identification number; and the delivery address.
(B) Include the supplier's shipping invoice, with the client's name; the shipping service package identification number; and a detailed description.
(iv) Make proof of delivery receipts available to the agency upon request.
(2) When billing drugs under the expedited authorization process, providers must insert the authorization number, which includes the corresponding criteria code or codes in the appropriate data field on the drug claim.
(3) Pharmacy services for clients on restriction under WAC 182-501-0135 must be prescribed by the client's primary care provider and are paid only to the client's primary pharmacy, except in cases of:
(a) Emergency;
(b) Family planning services; or
(c) Services properly referred from the client's assigned pharmacy or physician/ARNP.