CARVE-OUT ASSESSMENT Table 1 List the name of each parent site, off-site outpatient facility, and entity-owned outpatient pharmacy “retail” listed on HRSA 340B OPAIS in column 1. List the 340B ID of the parent and offsite outpatient facility(ies) in column 2. Note that entity-owned outpatient pharmacies do not have a 340B ID. For entity-owned “retail” outpatient pharmacies, list the 340B ID(s) for which the pharmacy is listed as a shipping “retail” address. Review the Medicaid Exclusion File for the period identified in step 2d of the instructions (page 1) to complete column 3. Table 1 Assessment Questions Yes No N/A Unsure 1. Are the Medicaid provider number (MPN) and National Provider Identifier (NPI) numbers used by the entity and entity-owned outpatient pharmacy(ies) to “retail” bill non-340B drugs excluded from the HRSA Medicaid Exclusion File? Answer to the question only if all answers are in column 3, “Yes” “YES” “Medicaid provider number (MPN) and National Provider Identifier (NPI) number(s) are not listed in the HRSA Medicaid Exclusion File” If response is or explain: (Identify and discuss each outlier) “No” “Unsure,”
CARVE-OUT ASSESSMENT Table 1 List the name of each parent site, off-site outpatient facility, and entity-owned outpatient “retail” pharmacy listed on HRSA 340B OPAIS in column 1. List the 340B ID of the parent and offsite outpatient facility(ies) in column 2. Note that entity-owned outpatient “retail” pharmacies do not have a 340B ID. For entity-owned outpatient “retail” pharmacies, list the 340B ID(s) for which the pharmacy is listed as a shipping address. Review the Medicaid Exclusion File for the period identified in step 2d of the instructions (page 1) to complete column 3. Table 1 Assessment Questions Yes No N/A Unsure 1. Are the Medicaid provider number (MPN) and National Provider Identifier (NPI) numbers used by the entity and entity-owned outpatient “retail” pharmacy(ies) to bill non-340B drugs excluded from the HRSA Medicaid Exclusion File? Answer “Yes” to the question only if all answers are “YES” in column 3, “Medicaid provider number (MPN) and National Provider Identifier (NPI) number(s) are not listed in the HRSA Medicaid Exclusion File” If response is “No” or “Unsure,” explain: (Identify and discuss each outlier)
DSH-Self-Audit-Prevention-of-Duplicate-Discounts.docx