Mich. Admin. Code 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.
Notes
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