• Editor: Vic Vangel • Contributors: Chris Burke, Gary Gilmore, Paul Jeffrey, James Monahan, Nancy Schiff • Flu Vaccine Update Effective November 1, 2010, MassHealth will pay pharmacies for the administration of flu vaccines to MassHealth-eligible members. All MassHealth members are eligible to receive flu vaccines regardless of coverage type (except where MassHealth pays only for premium assistance for members with other health insurance). Coverage of flu vaccines for MassHealth members enrolled in MassHealth managed care organizations (MCOs), including senior care organizations (SCOs) and Programs of All-inclusive Care for the Elderly (PACE), will be through the MCOs. Providers should use the MassHealth Eligibility Verification System (EVS) to check member eligibility and managed care enrollment. Vaccinations must be administered by properly trained and certified pharmacists and other health care professionals in accordance with Massachusetts Department of Public Health regulations at 105 CMR 700.000. Pharmacies may not charge MassHealth members a copayment for the vaccine administration or flu vaccine serum. MassHealth will pay pharmacies for flu vaccine serum without prior authorization if the vaccine is not available free of cost. Pharmacies must provide information to the member’s primary care clinician for the administration of flu vaccine. This information must include: • member name and date of birth, • vaccine name, quantity, and lot number • injection site of administration, and • date of administration. Pharmacies can obtain the PCC contact information from the MassHealth member or from the MassHealth EVS. Instructions for accessing EVS are given below. Pharmacies may bill only for vaccine administration through the Pharmacy Online Processing System (POPS) using the following instructions. • Include the NDC of the vaccine serum. • Enter a zero amount in the dispensing fee field. (MassHealth will pay an administration fee to pharmacies instead of a dispensing fee.). • Enter the value of “MA” in the field called “Professional Service” (440-E5). • Enter the appropriate administration fee in the field called “Incentive Amount Submitted” (438-E8) See chart below. • Include the cost of the vaccine serum, plus the administration fee, as the gross amount due. Payment Amounts for Vaccine Administration Vaccine Service Description Admin. Fee Flu vaccine, administered by injection $13.76 Flu vaccine, administered by intranasal route $9.06 * These fees are the current rates paid to a mid-level clinician in the DHCFP Medicine regulation and may change when these regulations are updated. Member Eligibility Verification System (EVS) Please check the MassHealth Eligibility Verification System to confirm eligibility and MassHealth member ID numbers. If you do not have the member’s MassHealth card or temporary ID, you can check eligibility by using either the social security number, or name with gender and date of birth. Providers can check member eligibility by telephone using the EVS, Automated Voice Response (AVR) system, which is available by calling 1-800-554-0042. Providers need to register with the Provider Online Service Center (POSC) before they can use the EVS and AVR. There are also several other Internet-based methods for checking member eligibility. See the applicable POSC instructions on the MassHealth Web site at www.mass.gov/masshealth/newmmis. Many providers already have access to the POSC, and hence EVS. There are guides on using the AVR on the Web at the following address. www.mass.gov/Eeohhs2/docs/masshealth/provlibrary/avr_userguide.pdf www.mass.gov/masshealth/pharmacy Number 61 October 28, 2010 Page 1 of 2 Temporary Identification Cards Some members receive MassHealth benefits on the same day as a temporary identification card is issued. When necessary, the MassHealth agency or the Department of Transitional Assistance issues a temporary MassHealth card to the cardholder for use until a plastic MassHealth card is issued. The temporary MassHealth card shows dates of eligibility, service restrictions, and other insurance information. If a discrepancy occurs between information given on a temporary MassHealth card and EVS, the information on the temporary card prevails. To be paid for a covered service that was provided based on information given on a temporary card, a provider must produce a copy of the temporary card, and have otherwise met all other prerequisites for payment. Reminders from MassHealth Rx Origin Code Pharmacies are reminded that a valid Rx Origin Code (NCPDP field 419-DJ) is to be entered on every pharmacy claim submitted through the Pharmacy Online Processing System (POPS). It is extremely important that the correct code is entered on every claim. The accepted values for this field are: 1 - Written Rx on tamper resistant pad 2 - Telephone Rx 3 - Electronically prescribed Rx 4 - Facsimile Rx Automatic Refills Pharmacies are reminded that prescriptions for a MassHealth member cannot be refilled automatically without a specific request being made for that refill. MassHealth pharmacy regulations at 130 CMR 406.411(C)(6) state that: The MassHealth agency does not pay for any refill without an explicit request from a member or caregiver for each filling event. The possession by a provider of a prescription with remaining refills authorized does not in itself constitute a request to refill the prescription. Provider Participation and the Payment Error Rate Measurement (PERM) Project PERM is designed by the Centers for Medicare & Medicaid Services (CMS) to measure improper payments in the Medicaid program, as required by the Improper Payments Information Act of 2002 (IPIA; Public Law 107-300). PERM regulations at 42 CFR 431.950 through 431.1002 (published in the Federal Register on October 5, 2005) direct states to work with CMS in developing a national payment error rate to comply with the IPIA. Massachusetts is one of 17 states participating in the CMS FY2010 PERM project. As part of the FY2010 PERM project, CMS will review a random sample of FY2010 MassHealth provider claims to test for data- processing accuracy and medical necessity. Providers whose claims are selected will be contacted directly by a CMS contractor to provide copies of their medical records and supporting documentation for the sampled claims. Provider cooperation to furnish requested records is critical. Insufficient documentation or failure to respond to the requests in a timely manner will be classified as an error. All claims classified as errors will result in a claim adjustment against the provider’s claim and may also result in an on-site visit. For more information about the PERM project, including patient privacy concerns, provider responsibilities, and specifics on claim-classification errors, refer to All Provider Bulletin 203 (March 2010). You can download a copy from the Provider Library on the MassHealth Web site at www.mass.gov/masshealth. Scroll down and click on the link for MassHealth Regulations and Other Publications, Provider Library, and then Provider Bulletins. The CMS PERM Web site also provides PERM-related information at www.cms.hhs.gov/PERM. If you have questions about PERM, there are several options. You can fax your inquiry to 617-988-8974, Attention: Massachusetts PERM Representative, contact MassHealth Customer Service at 1-800-841- 2900, or e-mail your question to david.kerrigan@state.ma.us. Usual and Customary Charge Pharmacies are reminded of the definition of usual and customary charge, which is contained in the Division of Health Care Finance and Policy (DHCFP) regulations at 114.3 CMR 31.02. Usual and Customary Charge. The lowest price that a Provider charges or accepts from any payer for the same quantity of a drug on the same date of service, in Massachusetts, including but not limited to the shelf price, sale price, or advertised price for any drug including an over-the-counter drug. If an insurer and the Eligible Provider have a contract that specifies that the insurer will pay an average or similarly computed fixed amount for multiple therapeutic categories of drugs with different acquisition costs, the fixed amount will not be the Provider’s usual and customary charge. Please direct any questions or comments (or to be taken off of this fax distribution) to Victor Moquin of ACS at 617-423-9830. Page 2 of 2 Pharmacy Facts, Number 61