For each contract pharmacy listed in Table 1, is the state Medicaid billing policy available? Answer to the question only if all answers are in the column titled “Yes” “Yes” Medicaid billing policy available” in Table 1. “State If response is or explain: “No, “Unsure,” For each contract pharmacy listed in Table 1, does the covered entity maintain a documented arrangement to prevent duplicate discounts with all applicable state Medicaid agencies? Answer to the question if all contract pharmacy locations carve out. “N/A” Answer to the question only if all answers are in the column titled “Yes” “Yes” arrangement with all applicable state Medicaid agencies to prevent “Documented duplicate discounts” in Table 1. If response is or explain: “No,” “Unsure, For each contract pharmacy listed in Table 1, is a Effective Date” listed in the HRSA 340B OPAIS? “Carve-In Answer to the question if all contract pharmacy locations carve out. “N/A” Answer to the question only if all answers are in the column titled “Yes” “Yes” with a Carve-In Effective Date in the HRSA 340B OPAIS” in Table 1. “Listed If response is or explain: “No” “Unsure” CONTRACT PHARMACY CARVE-IN MEDICAID BILLING ASESSMENT Table 2 Identify billing (e.g., BIN/PCN) used by the contract pharmacy to bill Medicaid claims. From the most recent 3-month contract pharmacy period of pharmacy dispensing records (including primary, secondary, and tertiary billing codes) randomly select 20 prescriptions for which Medicaid was the payer. Complete columns 1 through 5. Verify that the Medicaid carve-in practice matches the arrangement on file with HRSA and complete column 6.
For each contract pharmacy listed in Table 1, is the state Medicaid billing policy available? Answer “Yes” to the question only if all answers are “Yes” in the column titled “State Medicaid billing policy available” in Table 1. If response is “No, or “Unsure,” explain: For each contract pharmacy listed in Table 1, does the covered entity maintain a documented arrangement to prevent duplicate discounts with all applicable state Medicaid agencies? Answer “N/A” to the question if all contract pharmacy locations carve out. Answer “Yes” to the question only if all answers are “Yes” in the column titled “Documented arrangement with all applicable state Medicaid agencies to prevent duplicate discounts” in Table 1. If response is “No,” or “Unsure, explain: For each contract pharmacy listed in Table 1, is a “Carve-In Effective Date” listed in the HRSA 340B OPAIS? Answer “N/A” to the question if all contract pharmacy locations carve out. Answer “Yes” to the question only if all answers are “Yes” in the column titled “Listed with a Carve-In Effective Date in the HRSA 340B OPAIS” in Table 1. If response is “No” or “Unsure” explain: CONTRACT PHARMACY CARVE-IN MEDICAID BILLING ASESSMENT Table 2 Identify billing (e.g., BIN/PCN) used by the contract pharmacy to bill Medicaid claims. From the most recent 3-month contract pharmacy period of pharmacy dispensing records (including primary, secondary, and tertiary billing codes) randomly select 20 prescriptions for which Medicaid was the payer. Complete columns 1 through 5. Verify that the Medicaid carve-in practice matches the arrangement on file with HRSA and complete column 6.
covered-entity-self-audit-contract-pharmacy-prevention-of-duplicate-discounts.docx