37.85.905    PHYSICIAN-ADMINISTERED DRUGS, BILLING REQUIREMENTS

(1) Billable claim lines submitted for reimbursement of physician-administered drugs must:

(a) include a valid 11 digit NDC;

(b) include the drug quantity billed for each code;

(c) state the NDC unit of measure as one of the following:

(i) international unit - F2;

(ii) gram - GR;

(iii) milliliter - ML;

(iv) units - UN; or

(v) milligram � ME;

(d) include corresponding CPT/HCPCS codes; and

(e) include a drug price.

(2) Reimbursement will be made only on those drugs manufactured by companies that have a signed rebate agreement with the CMS.

(3) A nonrebatable drug with a medically accepted indication may be prior authorized at the department's discretion. Prior authorized drugs will be reimbursed according to provider type.

(4) Drugs and devices purchased under the 340B Drug Pricing Program are exempt from this rule.

(5) Providers participating in the 340B Drug Pricing Program:

(a) must not submit an NDC for claim lines that are billed utilizing physician-administered drugs purchased under the 340B Drug Pricing Program;

(b) must submit CPT/HCPCS code(s) with all claims submitted to Montana Medicaid;

(c) must bill Montana Medicaid their actual acquisition cost; and

(d) must notify Montana Medicaid of newly acquired 340B status immediately upon approval from the Office of Pharmacy Affairs.

(6) Providers may elect to "carve out" Medicaid clients from their 340B program activities when billing non-340B priced physician-administered drugs and register their intent with the Office of Pharmacy Affairs.

(7) Providers who have registered with the Office of Pharmacy Affairs:

(a) must bill all claims as described in (1)(a) through (e); and

(b) will be reimbursed according to their provider type.

History: 53-2-201, 53-6-113, MCA; IMP, 53-6-101, MCA; NEW, 2008 MAR p. 956, Eff. 5/9/08; AMD, 2008 MAR p. 2671, Eff. 12/25/08; AMD, 2012 MAR p. 2625, Eff. 1/1/13.