OAR 410-121-0150: Billing Requirements

(1) All 340B covered entities that fill Medicaid patient prescriptions with drugs purchased at the prices authorized under Section 340B of the Public Health Service Act shall bill Medicaid at the actual acquisition cost, plus the entity’s assigned professional dispensing fee. (2) Pharmacies that purchase drugs at Nominal Price outside of 340B or the Federal Supply Schedule shall bill their actual acquisition cost. (3) With the exception of Indian Health Service pharmacies and Tribal 638 pharmacies, pharmacies who purchase drugs through the Federal Supply Schedule must bill their actual acquisition cost. Refer to AI/AN rules OAR chapter 410, division 146 for billing rules for Indian Health Service pharmacies and Tribal 638 pharmacies. (4) When billing the Health Systems Division (Division) for drug products, the provider: (a) May not bill in excess of the usual and customary charge to the general public: (A) The sum of charges for both the product cost and dispensing fee may not exceed a pharmacy's usual and customary charge for the same or similar service; (B) When billing the Division for a prescription, the pharmacy shall bill the lowest amount accepted from any member of the general public who participates in the pharmacy provider's savings or discount program; (b) Shall indicate the National Drug Code (NDC) as it appears on the package from which the prescribed medications are dispensed; (c) Shall bill the actual metric decimal quantity dispensed; (d) Unless specifically provided by another rule, when clients have other insurances, shall bill the other insurances as primary and the Division as secondary; (e) When clients have Medicare prescription drug coverage, shall bill Medicare as primary and the Division as secondary. (5) When submitting a paper claim, the provider shall furnish accurately all information required on the 1.2 Universal Claims Form. (6) The prescribing provider’s National Provider Identifier (NPI) is mandatory on all fee-for-service client drug prescription claims. Claims shall deny for a missing or invalid prescriber NPI. An exception to this includes but is not limited to a prescribing provider who does not have an NPI for billing, but who prescribes fee-for-service prescriptions for clients under Coordinated Care Organizations (CCOs), prepaid health plans (PHPs), long-term care, or other capitated contracts. This provider is to be identified with the: (a) Non-billing NPI-assigned for prescription writing only; (b) Clinic or facility NPI until an individual NPI is obtained; or (c) Supervising physician’s NPI when billing for prescriptions written by the physician associate, physician students, physician interns, or medical professionals who have prescription writing authority. (7) Billing for Death With Dignity services: (a) Claims for Death With Dignity services may not be billed through the Point-of-Sale system; (b) Services shall be billed directly to the Division, even if the client is in a CCO or PHP; (c) Prescriptions shall be billed on a 1.2 Universal Claims Form paper claim form using an NDC number. Claims shall be submitted to the address indicated in the Division’s Supplemental Information for Pharmaceutical Services.