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
