Department of Health and Family Services

September 2004 ! No. 2004-78

To:

DispensingPhysicians

Family PlanningClinics

Federally QualifiedHealth Centers

NarcoticTreatmentServices

Pharmacies

HMOs and OtherManaged CarePrograms

Drug Utilization Review and PharmaceuticalCare Services May Be Submitted in the SameTransactionEffective for claims processed on andafter December 14, 2004, WisconsinMedicaid is enhancing the pharmacyreal-time claims submission process inthe Point-of-Sale system to allow aresponse to a Drug Utilization Reviewalert and Pharmaceutical Care serviceclaim to be submitted in the sametransaction.

Currently, Wisconsin Medicaid accepts only oneset of Drug Utilization Review (DUR) fieldsper transaction in the pharmacy Point-of-Sale(POS) system. Effective for claims processedon and after December 14, 2004, WisconsinMedicaid will accept up to two sets of DURfields per transaction. Providers may continueto send one set of DUR fields if the 439-E4,�Reason for Service,� field for both DUR andPharmaceutical Care (PC) are the same.However, the POS system enhancement willnow allow providers to submit both a responseto a DUR alert and a PC dispensing fee in thesame transaction.

As a reminder to providers, the pharmacy isrequired to obtain participant consent for PCservices prior to providing PC services forSeniorCare participants.

Required National Council forPrescription Drug Programs Fields forClaims Submissions and ReversalsWisconsin Medicaid requires the followingNational Council for Prescription DrugPrograms (NCPDP) version 5.1 fields whenproviders submit noncompound drug claims orreversals with a response to a DUR alert andPC dispensing fee:

Providers are required to have NCPDP field473-7E, �DUR/PPS Code Counter,� presentsince Wisconsin Medicaid, BadgerCare, andSeniorCare will now monitor that field for bothcompound and noncompound transactions.

For compound drug claims, providers are stillrequired to indicate a DUR/PPS LOE code todetermine compound drug dispensing feereimbursement. A PC service cannot be billedfor a compound drug.

NCPDP Field NCPDP Field Name

473-7E DUR/Prospective PaymentSystem (PPS) Code Counter

439-E4 Reason for Service

440-E5 Professional Service

441-E6 Result of Service

474-8E DUR/PPS Level of Effort(LOE)*

*The DUR/PPS LOE is only required on PCreimbursement claim submissions.

Wisconsin Medicaid and BadgerCare Service-Specific Information ! September 2004 ! No. 2004-782

The Wisconsin Medicaid and BadgerCareUpdate is the first source of program policy andbilling information for providers.

Although the Update refers to Medicaidrecipients, all information applies to BadgerCarerecipients and SeniorCare participants also.

Wisconsin Medicaid, BadgerCare, and SeniorCareare administered by the Division of Health CareFinancing, Wisconsin Department of Health andFamily Services, P.O. Box 309, Madison, WI53701-0309.

For questions, call Provider Services at(800) 947-9627 or (608) 221-9883 or visit our Website at dhfs.wisconsin.gov/medicaid/.

PHC 1250

Software Testing with WisconsinMedicaidPharmacy providers may test POS systemchanges at any time with Wisconsin Medicaid.Providers interested in software testing shouldcontact the Wisconsin Division of Health CareFinancing (DHCF) Electronic Data Interchange(EDI) Department for a test packet. Afterproviders receive a test packet, they maycontact their software vendor to coordinatetesting.

Providers should work closely with theirsoftware vendors, information technology staff,and software user guides to verify that POSclaims and reversals are submitted accuratelyaccording to the Wisconsin MedicaidCompanion Document to HIPAAImplementation Guide: NCPDP 5.1(Rev. 12/14/04). This document is available onthe �Electronic Data Interchange (EDI)Information� page of the Medicaid Web site atdhfs.wisconsin.gov/medicaid/. The NCPDP5.1 Implementation Guide is available from theNCPDP Web site at www.ncpdp.org/.

Providers and their software vendors cancontact the DHCF EDI Department if they areinterested in testing. For more information aboutthe EDI Department or testing, providers maycall the EDI Department at (608) 221-9036 ore-mail wiedi@dhfs.state.wi.us.

For More InformationProviders should refer to their WisconsinMedicaid Companion Document to HIPAAImplementation Guide: NCPDP 5.1(Rev. 12/14/04) for more information onNCPDP fields. Refer to the Drug UtilizationReview and Pharmaceutical Care section ofthe Pharmacy Handbook for WisconsinMedicaid�s policy on submitting claims for aresponse to a DUR alert and a PC dispensingfee.

Information Regarding MedicaidHMOsThis Wisconsin Medicaid and BadgerCareUpdate contains Medicaid fee-for-servicepolicy and applies to providers of services torecipients on fee-for-service Medicaid only. ForMedicaid HMO or managed care policy,contact the appropriate managed careorganization. Wisconsin Medicaid HMOs arerequired to provide at least the same benefits asthose provided under fee-for-servicearrangements.