All Indiana Health Coverage Programs Pharmacy Providers. Most Common Billing Unit Discrepancies That Result in Manufacturer Drug Rebate Disputes

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1 Indiana Hlth Coverage Programs P R O V I D E R B U L L E T I N B T A U G U S T 1 7, To: Subject: All Indiana Hlth Coverage Programs Pharmacy Providers Note: The information in this bulletin is not directed to those providers rendering services in the riskbased managed care (RBMC) delivery system. Overview For any drug manufacturer s products (both legend and over-thecounter) to be covered by the Traditional Medicaid Program the manufacturer must have entered into and have in effect a rebate agreement with the federal government. The essence of the agreement is that the manufacturer agrees to pay ch state, on a quarterly basis, a portion of the money that the state expended for that manufacturer s individual products. This process is based on the number of units of ch drug the state submits to the manufacturer for rebates. It is critically important that Traditional Medicaid Program providers submit the correct number of units on ch claim. The grtest number of manufacturer disputes is attributed to the number of units the state charges to the manufacturer. Some drug products have billable units that are obvious, for example, tablets or capsules are billed as ch. Other products, however injectable products, in particular do not have obvious correct billing units. IndianaAIM has built-in claims processing logic edits that were designed to identify potentially misbilled units. Even with such edits, some products have had a large number of manufacturer rebate disputes. The purpose of this bulletin and others that will follow on a periodic basis is to highlight products that analysis has shown to cause manufacturer disputes because of potentially misbilled units. EDS 1

2 Indiana Hlth Coverage Programs Plse be aware that incorrectly billed units cause unnecessary administrative time and resources on the part of both the state and rebating drug manufacturers and slows down the return to the state of the rebate-related proceeds. Also, manufacturers do retain the right to require audits of specific providers billing records, in the event of unresolved disputes. Careful adherence to correct billing of units will ensure that this is not required. According to records, Tables 1.1 and 1.2 relate those products most commonly disputed by rebating manufacturers. Table 1.2 lists the correct unit definition for drugs with substantial dispute activity. Definitions Plse be aware that there are only three, acceptable billing units for purposes of the Traditional Medicaid Program. They are as follows: Each () The billing unit for capsules, tablets, kits, and unreconstituted vials. Milliliters () The billing unit for liquid dosage form having a uniform concentration. Grams () The billing unit for products that are packaged by weight, such as ointments, crms, and powders that are not reconstitutable for injection. Factors Most Commonly Associated with Rebate-Related Disputes Analysis consistently revls the following factors as the most common causes of rebate disputes: Incorrect billing unit such as, using the number of milliliters in a vial as opposed to using ch to specify the entire contents of the vial Note: This example is for illustrative purposes only. Some products are billed by and some by ch vial. Provider data entry errors, including those involving decimal or fractional quantities Units billed exceeding what would be expected as being within a normal range for the product; for example, the billed units appr inconsistent with what a normally dispensed quantity would be EDS 2

3 Indiana Hlth Coverage Programs Charge amounts that suggest a generic might have been dispensed when a brand name National Drug Code (NDC) was submitted on the claim Providers are encouraged to contact the Indiana POS/ Pro-DUR Help Desk at if in the course of billing the Traditional Medicaid Program for dispensed drugs, there is a question on what constitutes the correct unit for that drug. All efforts to help minimize the number of manufacturer disputes are appreciated. Plse compare current billing practices to the indicated billing unit in the following tables to ensure consistency. Table 1.1 s for Commonly Billed Products Oral Antibiotic Suspensions All Oral Inhalers Ointments and Crms Ativan Tubex Syringes Rdy-To-Use IV Antibiotic Minibags Metamucil and Psyllium-like Products (Jar) Metamucil and Psyllium-like Products (Packet) Birth Control Pills Glucagon F 1 mg Emergency Kit Rocephin 10 Vial Norplant System (tablet) (kit) (kit) Table 1.2 contains a list of specific drug products and the correct billing unit. 2% XYLOCAINE VISCOUS SOL ACETAMINOPHEN TAB ADVIL 100MG /5ML SUSP ALBUTEROL.83MG/ML SOLN ALBUTEROL SULF 2MG/5ML SYRP ALLBEE W/C ALLOPURINOL TAB EDS 3

4 Indiana Hlth Coverage Programs ALPRAZOLAM 25MG TAB AMANTODINE 100MG CAP AMILORIDE HCL/HCTZ 5/50 TAB AMITRIP/PERPHEN TAB AMOXICILLIN SUSP AMOXICILLIN CAP AMPICILLIN TR 250MG CAP ANTI-DIARRHEAL 2MG CAP ANTURANE 200MG CAP AQUASOL 25000IU CAPSULE AQUASOL 50000U/ML VIAL AQUASOL E 50IU/ML DROPS ARTANE 2MG /5ML ELIXER ARTIFICIAL TEARS DROPS ARTIFICIAL TEARS EYE OINT ASA 325MG TAB ASCORBIC ACID 500MG TAB ASPIRIN 81MG TAB CHEW ATENOLOL 100MG TAB ATIVAN 2MG/ML TUBE X SYR ATIVAN 2MG/ML VIAL ATPRAXOLAM 0.25MG TAB ATROPINE 1% EYE DROPS AYGESTIN 5MG TAB AZMACORT INHALER BACITRACIN 500U/GM OINT. BACLOFEN TAB BANOPHEN 12.5MG/5ML ELIX BENZTROPINE MES 1MG TAB BETAMETHASONE VA.1% OINT BETHAPRIM MG TAB BISACODYL 10MG SUPPOSITORY EDS 4

5 Indiana Hlth Coverage Programs BISACODYL 5MG TAB EC BONDAMINE-DM SYRUP BREVICON 28 TAB BUTISOL SOD 30MG CALCIUM CARB CHEW CALCIUM W/VITAMIN D TAB CAPTOPRIL TAB CARBIDOPA/LEVO TAB CATAPLES-TTS PATCH CEFACLOR 250MG/5ML SUSP CENTRUM CENTRUM-LIQUID CERTA-VITE LIQUID CERTA-VITE TAB CHILD CHEW + IRON TAB CHEW CHILD CHEW VITAMIN TAB CHILDREN'S TYLEN 160MG/5ML CHLORDIAZIPOXIDE 25MG CAP CHOLINE MAQ TN SAL 750MG TB CIMETIDINE 200MG TAB CLEOCIN PHOS 150MG/ML VIAL CLINDAMYCIN PH 1% SOLUTION CLONIDINE HCL TAB CLOZAPINE TABS COLACE 100MG CORDARONE 200MG TAB CYCLOBENZAPRINE 10MG TAB CYPROHEPTADINE 2MG/5ML SYRUP DARVOCET-N DARVON-N 100MG TAB DECLOMYCIN TAB DELTASONE 5MG TAB EDS 5

6 Indiana Hlth Coverage Programs DEPO-PROVERA 100MG/ML VIAL DESIPRAMINE 25MG TAB DEXAMETHASONE.5MG/5ML ELX DIAMOX SEQUELS 500MG CAP SA DIAZEPAM TAB DICLOXACILLIN 500MG CAP DIFLUNISAL 500MG TAB DILTIAZEM TAB DIPHENHYDRAMINE 2% CREAM DIPHENHYDRAMINE CAP DOBUTAMINE 500MG/D5W 250ML DOCUSATE CALCIUM 240MG CAP DOCUSATE SODIUM 100MG CAP DOK 100MG CAP DOXEPIN CAP DSS/CASANTHRANOL 100/30 CAP DSS/CASANTHRANOL SYRUP DURAGESIC 100MCG/HR PATCH ECOTRIN 325MG TAB EC EFFEXOR TAB ERGOLOID MESYLATES 1MG TAB ETODOLAC CAP FARBITAL CAP FEIBA VH IMMUNO U VL FENOPROFEN 600MG TAB FEOSOL 220MG/5ML ELIXER FERROUS SULF 325MG TAB FIBER-EZE POWDER FIBER-EZE SMOOTH POWDER FLEET ENEMA FLUOCINOLONE.01% SOLN FLUOCINONIDE 0.05% OINTMENT EDS 6

7 Indiana Hlth Coverage Programs FLUPHENAZINE TAB FOLIC ACID 1MG TAB FORMULA B TAB FUROSEMIDE TAB FURROUS SULF 220MG/5ML ELIX GENTAMICIN 0.1% CREAM GEVRABON-LIQUID HALCION.125MG TAB HALOPERIDOL TAB HEM-PREP SUPPOSITORY HYDRALAZINE 25MG TAB HYDROCODONE/APAP 10/650 TAB HYDROCORTISONE 1% CREAM HYDROCORTISONE POWDER HYOSCYAMINE.375MG CAP SA IBUPROFEN TAB ILETIN II PORK LEN 100U/ML IMIPRAMINE 50MG TAB IMITREX 6MG VIAL INDERAL LA CAP INFANT'S TYLENOL DROPS INFERGEN 15MCG/0.5ML VIAL IRON CAPLET W/STOOL SOFTENER IRON FOLIC 500MG TAB SA ISORDIL 40MG TAB ISOSORBIDE DN TAB KADIAN 100MG CAP SR KEFLEX 250MG/5ML ORAL SUSP KETOPROFEN 75MG CAP LACTULOSE 10GM/15ML SYR LEVAQUIN 500MG LEVOTHYROXINE TAB EDS 7

8 Indiana Hlth Coverage Programs LODINE CAP LODINE XL 600MG LOPRESSOR HCT LORAZEPAM TAB LOXAPINE SUCCINATE 5MG CAP L-THYROXINE TAB M.V.I. VIAL M.V.I. 12 COMBO PKG MAALOX PLUS SUSP MAJOR TEARS DROPS MAJOR TEARS EYE OINTMENT MAPROTILINE 25MG TAB MATULANE 50MG CAP MAXAQUIN 400MG MELLARIL 10 MG TAB METAMUCIL METAPROTERENOL TAB METHAZOLAMIDE TAB METHENAMINE MD 500MG TAB EC METHOTREXATE METHYLDOPA 500MG TAB METHYLPHENIDATE 20MG TAB METHYLPHENIDATE 20MG TAB SA METOCLORPRAMIDE 5MG TAB METOPROLOL TAB MICRO-K 10 MEQ MILK OF MAGNESIA SUSP MINERAL OIL NAPROXEN 375MG NASALCROM 4% NIACIN CAP SA NIACIN TAB EDS 8

9 Indiana Hlth Coverage Programs NIFEDIPINE 10MG CAP NITROFURANTION NITROGLYCERINE NITROGLYCERINE.2MG/HR PATCH NORINYL TAB NOVOLIN 70/30 CARTRIDGE NOVOLIN N 100U/ML CARTRIDGE NOVOSEVEN 4800MCG NYSTATIN CREAM U/GM ORA-SWEET SF SYRUP ORUVAIL 200 MG CAP SA OXYCODONE W/APAP 5/325 TAB OYSTER + D 500MG TAB OYSTER SHELL 500 MG TAB OYSTER SHELL CAL 500MG TAB OYSTER SHELL W/VIT. D TAB PENICILLIN VK TAB PERI-COLACE PERPHENAZINE TAB PHENAZOPYRIDINE TAB PHENERGAN SUPPOSITORY PHENERGAN TAB PHENERGAN 25MG/ML AMPULE PHENERGAN 25MG/ML TUBE X SYR PHOSPHATE ENEMA PHOSPHOLINE IODIDE.25% PIPERONYL BUTOXIDE LIQUID POLY-VI-SOL DROP POLY-VI-SOL IRON, ZN TAB POTASSIUM CHLORIDE 20% LIQUID POTASSIUM CL TAB SA PRAZOSIN 1MG CAP EDS 9

10 Indiana Hlth Coverage Programs PREDNISONE 20MG TAB PREMARIN TAB PREMARIN VAGINAL CREAM REFL PREMARIN VAGINAL CREAM/APPL PREMPRO TAB PRENATAL 1 TABLET PROCAINAMIDE 500MG TAB SA PROCHLORPERAZINE 5MG/ML VL PROGESTERONE PWD MICRONIZED PROMETHAZINE 25MG/ML AMPUL PROMETHAZINE 6.25MG/5ML SYR PROPOXY-N APAP TAB PROPRANOL/HCTZ TAB PROPRANOLOL CAP SA PSEUDO-CHLOR CAP SA PSEUDO-G/PSI TAB SA PYRIDOXINE 50MG QUIBRON-T-SR QUININE SULFATE CAP QUININE SULFATE TAB REGLAN TAB RENTAMINE PEDIATRIC SUSP ROBAFEN-DAC SYRUP ROBAXISAL ROBINUL.2MG/ML VIAL ROBINUL 1MG SELEGILINE HCL 5MG TAB SENNA TABLET SILVER SULFADIAZINE 1% CREAM SLO-BID 300 GYRO CAPS SODIUM BIC 650MG TAB SODIUM BICARB 8.4% VIAL EDS 10

11 Indiana Hlth Coverage Programs SODIUM CHLORIDE 0.9% AMPULE STELAZINE 10MG TAB STRESS FORMULA/ZINK TAB STRESS-600 TAB SUDOGEST 30MG TAB SULFAMIDE 10% EYE DROPS SYNVISC-SYRINGE TENEX TAB 2MG TESTOSTERONE POWDER THEOPHYLLINE CAP SA THEOPHYLLINE TAB SA THEOPHYLLINE 80MG/15ML ELIX THERA LIQUID THERA TABLET THERAPEUTIC MULTIVIT TAB THIAMINE 100MG THIORIDAZINE 10MG TAB THIOTHIXENE CAP TIMENTIN 3.1 GM RTU BAG TOLAZAMIDE 250MG TAB TRANSDERM-SCOP 1.5MG/72HR TRIAMTERENE/HCTZ 50/25 CAP TRI-FAC CAPSULE TRIFLUOPERAZINE 10MG TAB TRI-NORINYL TAB TRINSICON CAP TRI-VI-SOL DROPS TUMS 500 TAB CHEWABLE UNICAP TAB VENTOLIN 90 AEROSOL VERELAN PELLET 120MG CAP VI-C FORTE CAP EDS 11

12 Indiana Hlth Coverage Programs VIT A CAP VIT B-1 TAB VIT C CAP SA VIT C TAB VIT E CAP VITAMIN A SOFTGEL VITAMIN D TAB VIVELLE PATCH XALATAN 0.005% ZIAC TAB ZINC GLUCONATE 50MG TAB ZINC OXIDE OINT ZOSYN 3/3.75G PRE-MIX BAG EDS 12