Additional Resourcesįee-for-Service PA Criteria Sheet – Diabetic Testing Supplies MHCP authorization is not required if the other insurance pays 60 percent or more of the allowed rate for a nonpreferred meter or test strips. Private Insuranceįollow the rules of other insurance, including use of preferred products, network providers, authorizations and billing requirements when dispensing pharmacy POS diabetic supplies. Dual eligible members are not limited to preferred brands dispense any brand of meter or strip for dual eligible members. MHCP will pay the deductible and coinsurance amount reported on the Medicare explanation of medical benefits (EOMB). Bill Medicare first, then send the crossover claim to MHCP. Dual Eligible Recipientsĭo not bill the MHCP pharmacy POS benefit for diabetic testing supplies dispensed to Medicare dual-eligible members. All claims for medical supplies, including diabetic testing supplies submitted by FQHCs, RHCs and IHS pharmacies are paid at zero because the supplies are considered incidental to paid encounters. FQHCs, RHCs and IHS facilities are not required to use the preferred products and may submit pharmacy POS claims or 837P claims for any brand of meter and strips without prior authorization. FQHC, RHC and IHSįederally qualified health centers (FQHCs), rural health clinics (RHCs) and Indian Health Services (IHS) providers, including IHS pharmacies, do not receive a separate encounter rate for dispensing medical supplies, including diabetic testing supplies. For example, if the member tests once weekly, dispense a box of 25 test strips (175 day supply) and a box of 100 lancets (180 day supply). If the smallest package exceeds a day’s supply of 180 days, enter 180 days as the day supply. To minimize waste, dispense the manufacturers smallest package size available. Providers must dispense an entire unopened box of test strips or lancets. Continue to bill MHCP for supplies not included in the POS benefit as DME using the appropriate HCPCS codes on the 837P claim.
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Submit claims for MHCP fee-for-service members using the appropriate NDC codes.
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MHCP will not pay a pharmacy dispensing fee for diabetic testing supplies. Wholesale Acquisition Cost (WAC) minus 2%