March 1 for Managed Care Expansion

Posted 13 February 2012 by aborgmeyer & filed under newsroom, Provider News.

Beginning Thursday, March 1, 2012, Managed care organizations (MCOs) that contract with the Health and Human Services Commission will administer prescription drug benefits and payments for Medicaid managed care and Children’s Health Insurance Program (CHIP) clients. Each MCO will contract with a pharmacy benefits manager (PBM) that will process prescription claims and contract and work with pharmacies that serve CHIP and Medicaid managed care clients.

Beginning March 1, the Vendor Drug Program will:

• Still enroll pharmacy providers that want to provide Medicaid and CHIP services.
• Continue to manage Vendor Drug Medicaid and CHIP formularies.
• Continue to process claims for clients enrolled in fee-for-service Medicaid, the Children with Special Health Care Needs (CSHCN) Services Program, and the Kidney Health Care (KHC) Program.
• Deny claims for clients enrolled in Medicaid managed care or CHIP with National Council for Prescription Drug Programs error code “AF” (“Patient Enrolled Under Managed Care”). The name of the responsible Medicaid or CHIP health plan will be returned in “Additional Message Information” (Field 526-FQ).

MCOs should be offering pharmacy provider training sessions leading up to the March 1 transition. Pharmacy staff is encouraged to attend and learn the procedures for submitting claims, where to call for claim overrides or prior authorization assistance, and any other unique claim policies/procedures for Medicaid and CHIP clients.

Additional resources such as billing details, frequently asked questions, and information on how to identify a client’s MCO membership will be sent to pharmacies and will be available anytime at txvendordrug.com.