R 418.10912 Billing for prescription medications.

Rule 912. (1) Prescription drugs may be dispensed to an injured worker by either an outpatient pharmacy or a healthcare organization. These rules apply to the pharmacy dispensing the prescription drugs to an injured worker only after the pharmacy has either written or oral confirmation from the carrier that the prescriptions or supplies are covered by workers' compensation insurance. (2) When a generic drug exists, the generic drug must be dispensed. When a generic drug does not exist, the brand name drug may be dispensed. A physician may only write a prescription for "DAW," or dispense as written, when the generic drug has been utilized and found to be ineffective or has caused adverse effects for the injured worker. A copy of the medical record documenting the medical necessity for the brand name drug must be submitted to the carrier. (3) A bill or receipt for a prescription drug from an outpatient pharmacy, practitioner, or healthcare organization must be submitted to the carrier and include the name, address, and Social Security number of the injured worker. An outpatient pharmacy shall bill the service using the National Council for Prescription Drug Program (NCPDP) Workers’ Compensation/Property & Casualty Universal Claim Form or an invoice and include either the pharmacy’s NPI or NCPDP number, and the NDC of the prescription drug. (4) A healthcare organization or physician office dispensing the prescription drug shall bill the service on the CMS 1500 claim form. Procedure code 99070 must be used to code the service and the national drug code must be used to describe the drug. (5) If an injured worker has paid for a prescription drug for a covered work illness, then the worker may send a receipt showing payment, along with the drug information, to the carrier for reimbursement. (6) An outpatient pharmacy or healthcare organization shall include all of the following information when submitting a bill for a prescription drug to the carrier: (a) The brand or chemical name of the drug dispensed. (b) The NDC number from Red Book or Medi-Span, as adopted by reference in R 418.10107. (c) The dosage, strength, and quantity dispensed. (d) The date the drug was dispensed. (e) The physician prescribing the drug. (7) A practitioner or a healthcare organization, other than an inpatient hospital, shall bill a dispense fee for each prescription drug. A provider shall only be reimbursed for 1 dispense fee for each prescription drug in a 10-day period. A dispense fee must not be billed with "OTC"s, over-the-counter drugs.