Skip to main content
  • Medicaid Provider Alert: Provider revalidation has begun and those not completing the process risk disenrollment.  Check your account now to learn when your revalidation is due. More information here.
Elizabeth M. Whitehorn, Director

Provider Notice issued 11/10/14

Submittal of Claims for Multi-Use Vials

To:​ Enrolled Physicians, Advanced Practice Nurses, Federally Qualified Health Centers, Rural Health Clinics, Encounter Rate Clinics and Local Health Departments ​
​Date: ​November 10, 2014
​Re: Submittal of Claims for Multi-Use Vials​

 

A recent federal audit revealed the inappropriate billing practice with regard to claims submitted for multi-use vials of medications. While this particular audit focused on Herceptin, the guidelines below are applicable to all non-pharmacy providers when submitting claims for all multi-use vials. 

 

When billing the department for a multi-use vial, providers must only bill for the quantity of the drug actually dispensed. Claims submitted for an entire vial, when a partial vial was used are subject to audit and/or recoupment of any payment made for the unused portion of the medication.

Special Information Regarding Care Coordination Billing and Eligibility

 

The billing information in this notice applies to patients enrolled in traditional fee-for-service, Accountable Care Entities (ACEs) and Care Coordination Entities (CCEs) and does not apply to patients enrolled in Managed Care Organizations (MCOs) and Managed Care Community Networks (MCCNs).

It is imperative that providers check HFS electronic eligibility systems regularly to determine beneficiaries’ enrollment in a plan. Electronic Data Interchange vendors (formerly the Recipient Eligibility Verification (REV) System), the Automated Voice Response System (AVRS) at 1-800-842-1461, and the Medical Electronic Data Interchange (MEDI) system will identify any care coordination plan in which the beneficiary is enrolled. Plan contact information for questions related to coverage and billing requirements as well as information regarding the way each plan is displayed in the department’s electronic eligibility systems may be located in the June 24, 2014 informational notice titled, Revised - Care Coordination Enrollment for Children, Families and ACA Adults .

If you have additional questions, please contact a billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565 Option 3, then Option 1.

 

 

Theresa A. Eagleson, Administrator

Division of Medical Programs