DCH-i [Dec. 2015]

Special Bulletin:
December 2015

Billing Instructions for 340B Drug Claims Submission

Effective April 1, 2016, the Department of Community Health will change the way that it identifies 340B drugs for exclusion from rebates. DCH will stop utilizing the HRSA exclusion list, and all 340B drugs identified on pharmacy and medical claims must be billed using the following information per applicable Category of Service (COS).

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COS 300: Outpatient Pharmacy Claims submitted via the NCPDP format to the Pharmacy Benefit Manager (PBM) must include the Submission Clarification Code 20 and the National Drug Code (NDC). Covered Entities must bill the Division the non-profit dispensing fee in addition to the actual acquisition cost of the drug.

COS 321: Outpatient Pharmacy Crossover Claims must be submitted on a CMS 1500 through the Georgia Medicaid Management Information System (GAMMIS) and include a HCPCS code, UD Modifier, NDC and the actual acquisition cost of the drug.

COS 070: Outpatient Services Claims must be submitted on a UB-04 claim form with the actual acquisition cost of the drug through the GAMMIS. Claim level identifiers must include a HCPCS code, UD Modifier, NDC, Revenue Code 253 for oral drugs and Revenue Code 636 for injectable drugs. Claims submitted for injectable drugs with temporary HCPCS codes (i.e.: J3490, J3590), Q-codes or C-codes must also include the UD modifier and Revenue Code 636.

COS 541: Hospital-Based Rural Health Centers Claims must be submitted on a UB-04 claim form with the actual acquisition cost of the drug through the GAMMIS. Claim-level identifiers must include a HCPCS code, UD Modifier, NDC, Revenue Code 253 for oral drugs and Revenue Code 636 for injectable drugs. Permanent or temporary injectable drug HCPCS (i.e. J3490, J3590, Q-codes or C-codes) must also include the UD modifier and Revenue Code 636.

Please Note: COS 541 providers attached to Critical Access Hospitals will only be reimbursed the acquisition cost for the billed 340B drugs and will not receive a percentage of charge rate.

If you have any questions regarding Georgia Medicaid's policy on the 340B program, please contact the Department by e-mail at 340B@dch.ga.gov.

Thank you for your continued service and participation in the Georgia Medicaid & PeachCare for Kids Programs.

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About DCH
Through effective planning, purchasing and oversight, the Department of
Community Health (DCH) provides access to affordable, quality health care to millions of Georgians, including some
of the state's most vulnerable and underserved populations.
DCH is responsible for Medicaid and PeachCare for Kids, the State Health
Benefit Plan, Healthcare Facility Regulation and Health Information
Technology in Georgia. Clyde L. Reese III, Esq. is Commissioner of the Georgia Department of Community Health.
We are dedicated to A Healthy Georgia. www.dch.georgia.gov

DCH Mission
We will provide Georgians with access to affordable quality health care through
effective planning, purchasing and oversight.
We are dedicated to A Healthy Georgia.

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