Out-of-state pharmacy provider payment and billing methodology
Governance of Alaska Medicaid pharmacy coverage and payment methodology for out-of-state pharmacy providers submitting POS claims; describes ingredient cost, dispensing fee, usual & customary pricing, other amount claimed, gross amount due, and mediset fee billing rules effective September 7, 2011.
Estimated Acquisition Cost (EAC) will be based on Wholesale Acquisition Cost (WAC) instead of Average Wholesale Price (AWP) for out-of-state providers; new EAC = WAC + 1%.
Submitted ingredient cost (NCPDP field 409-D9) is now required; claims with no value in field 409-D9 or for products with no published WAC, SMAC or FUL will be denied.
SMAC will be published, maintained and updated weekly by Magellan Medicaid Administration and requests for reconsideration must be submitted with a completed Alaska Medicaid MAC Price Research Request Form and invoice.
Dispensing fee payment limited to one fee per medication strength per recipient per 28 days at the lesser of assigned $3.50 or dispensing fee submitted in NCPDP field 412-DC.
Mediset fee may be paid when claim includes Unit Dose Indicator 429-DT = 3, Patient Location 307-C7 = 6, and mediset fee in Other Amount Claimed field 480-H9; mediset fee only when service is performed and ordered.
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