WAC 182-530-5000 Billing requirements - Pharmacy claim payment

WAC 182-530-5000 Billing requirements—Pharmacy claim payment.

Revised March 14, 2021

  1. When billing the medicaid agency for pharmacy services, providers must:
    1. Use the appropriate agency claim form or electronic billing specifications;
    2. Include the actual eleven-digit national drug code (NDC) number of the product dispensed from a rebate eligible manufacturer;
    3. Bill the agency using metric decimal quantities which is the National Council for Prescription Drug Programs (NCPDP) billing unit standard;
    4. Meet the general provider documentation and record retention requirements in WAC 182-502-0020; and
    5. Maintain proof of delivery receipts.
      1. When a provider delivers an item directly to the client or the client's authorized representative, the provider must be able to furnish proof of delivery, including the signature of either the client or the provider, the client's name, and a detailed description of the item or items delivered.
      2. When a provider mails an item to the client, the provider must be able to furnish proof of delivery including a mail log.
      3. When a provider uses a delivery or shipping service to deliver items, the provider must be able to furnish proof of delivery and it must:
        1. Include the delivery service tracking slip with the client's name or a reference to the client's package or packages; the delivery service package identification number; and the delivery address.
        2. Include the supplier's shipping invoice, with the client's name; the shipping service package identification number; and a detailed description.
      4. Make proof of delivery receipts available to the agency upon request.
  2. When billing drugs under the expedited authorization process, providers must insert the authorization number, which includes the corresponding criteria code or codes in the appropriate data field on the drug claim.
  3. Pharmacy services for clients on restriction under WAC 182-501-0135 must be prescribed by the client's primary care provider and are paid only to the client's primary pharmacy, except in cases of:
    1. Emergency;
    2. Family planning services; or
    3. Services properly referred from the client's assigned pharmacy or physician/ARNP.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.