Required NCPDP Format for Real-Time Pharmacy Claims

Effective October 1, 2003, pharmacy claims submitted through the Point of Service (POS) network must use the National Council for Prescription Drug Programs (NCPDP) Version 5.1 format. Pharmacy claims received in the NCPDP Version 3.2 format will be denied.

New Methods for Submitting Compound Drug Claims

Pharmacy providers may submit compound drug claims for dates of service on or after September 22, 2003 using one of the following new methods:

• The real-time Point of Service (POS) network using the pharmacy computer software
• The Real-Time Internet Pharmacy (RTIP) application using the pharmacy computer and Internet browser
• The new paper Compound Drug Pharmacy Claim Form (30-4)

Note: Only claims for dates of service on or after September 22, 2003 can be submitted using the above new methods. Claims for dates of service prior to September 22, 2003 must be submitted on the Pharmacy Claim Form (30-1) with a Compounded Drug Attachment. Compound drug claims may be submitted using the 30-1 form until April 1, 2004.

The new Compound Drug Pharmacy Claim Form (30-4) can be ordered by calling the Provider Support Center (PSC) at 1-800-541-5555.

Billing for Medical Supplies and Empty Containers

Effective for dates of service on or after October 1, 2003, medical supplies and empty containers used to prepare compounds must be billed separately from compound drug claims on either the Pharmacy Claim Form (30-1) or the HCFA 1500 claim form using current Medi-Cal codes for medical supplies. Such items may not be billed as part of a compound drug claim and will not be reimbursed as ingredients using the new compound-drug billing methods.

Prior authorization is still required for any item that normally requires a Treatment Authorization Request (TAR), regardless of whether the item is billed on a single drug claim or as an ingredient on a compound drug claim.

Change to Code I Restriction for Parenteral Nutrition and I.V. Lipids

Effective for dates of service on or after September 22, 2003, the Code I restriction on Parenteral Nutrition Solutions (TPN or Hyperalimentation) and Separately Administered Intravenous Lipids is standardized to match Code I restrictions for Intravenous Solutions of Unlisted Antibiotics and Intravenous Solutions of Other Unlisted Drugs. The new Code I restriction reads:

"Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same product was started before discharge. There is a maximum of 10 days supply per dispensing within the 10-day period."

Creating a standardized 10-day period is expected to improve the consistency of claim payments.

When billing compound drugs that satisfy the Code I restriction using the 30-4 claim form, enter the hospital discharge date in the Hospital Discharge Date field (Box 38) and enter a "Y" in the Code I (Restrictions) Met? field (Box 13).

Similarly, when billing compound drugs that satisfy the Code I restriction using the 30-1 claim form, enter the hospital discharge date in the Discharge Date field (Box 91) and enter a "Y" in the Code I (Restrictions) Met? field (Box 14).