Reimbursement

Reimbursement A. The Division of Medicaid reimburses for: 1. Office visits only with the Beneficiary Health Management (BHM) designated physician, 2. Drugs prescribed only by the BHM designated physician, by the consultant physician, or by an emergency department physician, and 3. Drugs dispensed only by the BHM designated pharmacy provider. B. The Division of Medicaid requires post utilization review by the Division of Medicaid or designee for reimbursement to physician and/or pharmacy provider(s) other than the BHM designated physician and/or pharmacy provider(s) when : 1. Emergency care is required and the BHM designated physician and/or pharmacy provider is not available, or 2. The BHM designated physician and/or pharmacy provider requires consultation with another physician and/or pharmacy provider. C. BHM designated physician and/or pharmacy providers are required to bill the specified procedure codes if counseling sessions are provided. 1. The counseling procedure codes can be billed in conjunction with any other service the BHM designated physician provides to the beneficiary. 2. Documentation must support billing of the specified procedure codes by the BHM designated physician and/or pharmacy. D. The Division of Medicaid reimburses for inpatient hospitalization for treatment of alcohol and/or drug abuse when the diagnosis is a substance use disorder diagnosis in accordance with the most current Diagnostic and Statistical Manual (DSM) of Mental Disorders and the inpatient hospital stay is prior authorized by the Division of Medicaid or designee.