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Provider Notice Issued 06/16/2021

Date:    June 16, 2021

 

To:       Enrolled Hospitals:  Chief Executive Officers; Chief Financial Officers; and Patient Accounts Managers; and Renal Dialysis Centers

     

Re:      Pricing Recalculation for 340B Purchased Renal Dialysis Injectable Drugs

 

 

This notice provides updated information related to outpatient institutional claims and the $12.00 dispensing fee allowed for specific renal dialysis injectable drugs purchased through the 340B Program. This applies only to claims billed under the Medicaid fee-for-service program and does not apply to claims billed under a Medicaid managed care plan. Managed care plan payments are 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, providers have been instructed to bill modifier “UD” and add a $12.00 dispensing fee to the actual acquisition cost (AAC) of a drug on the Renal Dialysis Injectable Drug List when billing the Department for a 340B-purchased drug. Reimbursement for the injectable drugs was based on the current Practitioner Fee Schedule, with the understanding that the Department would eventually recalculate and adjust any incorrectly paid claims.

 

The Department has recently completed modifications to its processing system to add AAC and the $12.00 dispensing fee to its database and is preparing to run adjustments on claims containing these renal dialysis injectable drugs for dates of service beginning February 1, 2013 through claims received June 9, 2021. The adjustment pricing logic will compare the AAC of the drug plus the $12.00 dispensing fee to the provider’s line item charges for the drug and pay up to the maximum $12.00. HFS pricing is capped at the line charges. If the provider’s line item charges are less than the HFS price calculation of AAC plus the $12.00 dispensing fee, HFS will pay up to the provider’s line item charges.

 

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

 

Effective June 10, 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 billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.

 

 

 

Kelly Cunningham, Administrator

Division of Medical Programs​



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