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Elizabeth M. Whitehorn, Director

Provider Notice Issued 06/16/2021

Date:    June 16, 2021

 

To:       EnrolledHospitals:  Chief Executive Officers;Chief Financial Officers; and Patient Accounts Managers; and Renal DialysisCenters

     

Re:      Pricing Recalculation for 340B Purchased RenalDialysis Injectable Drugs

 

 

 

Thisnotice provides updated information related to outpatient institutional claimsand the $12.00 dispensing fee allowed for specific renal dialysis injectable drugspurchased through the 340B Program. This applies only to claims billed underthe Medicaid fee-for-service program and does not apply toclaims billed under a Medicaid managed care plan. Managed care plan paymentsare subject to contract agreements between the MCO and provider.

 

Per provider notice dated May 15, 2013, and the Handbook for Hospital Services, Topic

H-276.3, providershave been instructed to bill modifier “UD” and add a $12.00 dispensing fee tothe actual acquisition cost (AAC) of a drug on the Renal Dialysis Injectable Drug List when billing the Department for a 340B-purchaseddrug. Reimbursement for the injectable drugs was based on the current Practitioner Fee Schedule, with the understanding that the Department wouldeventually recalculate and adjust any incorrectly paid claims.

 

TheDepartment has recently completed modifications to its processing system to addAAC and the $12.00 dispensing fee to its database and is preparing to run adjustmentson claims containing these renal dialysis injectable drugs for dates of servicebeginning February 1, 2013 through claims received June 9, 2021. The adjustmentpricing logic will compare the AAC of the drug plus the $12.00 dispensing feeto the provider’s line item charges for the drug and pay up to the maximum$12.00. HFS pricing iscapped at the line charges. Ifthe provider’s line item charges are less than the HFS price calculation of AACplus the $12.00 dispensing fee, HFS will pay up to the provider’s line itemcharges.

 

Adjustmentswill be identified on the Remittance Advice with new Adjustment Reason Code  3560 - 340B Repricing.

 

Effective June10, 2021, any claim containing a renal dialysis injectable drug is automatically priced using the above logic.

 

Questions regarding this notice may be directed to a hospital billingconsultant in the Bureau of Professional and Ancillary Services at877-782-5565.

 

 

 

Kelly Cunningham, Administrator

Division of Medical Programs​