ims : Submission
Providers may submit claims for compound drugs through the following:
Providers are required to indicate an NDC for each component on claims for compound drugs. Claims for injectible drugs (IV, IM, subcutaneous, TPN solution, and lipids) with more than one component should be submitted as compound drugs.
ForwardHealth covers certain APIs and Excipients on compound drug claims. Providers should refer to the Covered Active Pharmaceutical Ingredients (APIs) and Excipients list for covered APIs and Excipients.
An API is a bulk drug substance, which is defined by the FDA as any substance that is represented for use in a drug and that, when used in the manufacturing, processing, or packaging of a drug, becomes an active ingredient of the drug product. Excipients are inactive substances used in compounds.
Providers should indicate time spent preparing a compound drug on a claim. BadgerCare Plus, Medicaid, and SeniorCare note the time indicated and, as a result, are better able to price the compound drug when an unusual amount of time is required to prepare the compound drug.
Providers are required to indicate the time (in minutes) to compound the prescription by using a level of effort code. The maximum amount of time that providers will be reimbursed is 30 minutes. Providers may indicate level of effort codes 14 and 15 to indicate that compounding the drug took more than 30 minutes, but they will only be reimbursed for up to 30 minutes. In calculating level of effort, providers should not include non-professional staff time, set-up time, or clean-up time in the total.
The usual and customary charge should include both the dispensing fee and the cost of the drug ingredients. On paper claims, indicate the usual and customary charge in the "Total Billed Amount" field. On real-time and PES claims, include the dispensing fee and the cost of the drug ingredients in both the "Usual and Customary Charge" field and in the "Gross Amount Due" field. (Note: Real-time claims must also adhere to the NCPDP balancing standards.) On Portal claims, indicate the dispensing fee and the cost of the drug ingredients in the "U&CC" field and in the "Charges" fields.
All of the ingredients of a compound drug must be billed as one compound drug. Claims for individual items of a compound drug may not be submitted separately with an accompanying dispensing fee for each ingredient. The quantity field should be the total number of units that are dispensed. This number is not the total number of units for each individual ingredient.
When submitting real-time claims for compound drugs, pharmacy providers should enter a value of "2" in the compound drug field. This alerts the POS system that the NDCs indicated comprise a single compound drug.
If one or more of the ingredients in a compound drug are not present on the drug file, the provider may choose not to bill the ingredient(s) not on file. The provider should submit the remaining ingredients on the Compound Drug Claim form using the previously defined billing instructions.
If a compound drug has any noncovered ingredients, payment for those ingredients will be denied, but the rest of the ingredients will be covered, assuming other conditions are met.
The BadgerCare Plus Standard Plan, Medicaid, and SeniorCare do not cover compounded medications in dosage forms that have no proven therapeutic effect.
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Topic
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Compound Drugs
Providers may submit claims for compound drugs through the following:
- The real-time POS system using the NCPDP Telecommunication Standard.
- On the ForwardHealth Portal.
- Using PES software.
- On a Compound Drug Claim form.
Providers are required to indicate an NDC for each component on claims for compound drugs. Claims for injectible drugs (IV, IM, subcutaneous, TPN solution, and lipids) with more than one component should be submitted as compound drugs.
ForwardHealth covers certain APIs and Excipients on compound drug claims. Providers should refer to the Covered Active Pharmaceutical Ingredients (APIs) and Excipients list for covered APIs and Excipients.
An API is a bulk drug substance, which is defined by the FDA as any substance that is represented for use in a drug and that, when used in the manufacturing, processing, or packaging of a drug, becomes an active ingredient of the drug product. Excipients are inactive substances used in compounds.
Compound Drug Preparation Time
Providers should indicate time spent preparing a compound drug on a claim. BadgerCare Plus, Medicaid, and SeniorCare note the time indicated and, as a result, are better able to price the compound drug when an unusual amount of time is required to prepare the compound drug.
Providers are required to indicate the time (in minutes) to compound the prescription by using a level of effort code. The maximum amount of time that providers will be reimbursed is 30 minutes. Providers may indicate level of effort codes 14 and 15 to indicate that compounding the drug took more than 30 minutes, but they will only be reimbursed for up to 30 minutes. In calculating level of effort, providers should not include non-professional staff time, set-up time, or clean-up time in the total.
The usual and customary charge should include both the dispensing fee and the cost of the drug ingredients. On paper claims, indicate the usual and customary charge in the "Total Billed Amount" field. On real-time and PES claims, include the dispensing fee and the cost of the drug ingredients in both the "Usual and Customary Charge" field and in the "Gross Amount Due" field. (Note: Real-time claims must also adhere to the NCPDP balancing standards.) On Portal claims, indicate the dispensing fee and the cost of the drug ingredients in the "U&CC" field and in the "Charges" fields.
Billing Compound Drug Ingredients
All of the ingredients of a compound drug must be billed as one compound drug. Claims for individual items of a compound drug may not be submitted separately with an accompanying dispensing fee for each ingredient. The quantity field should be the total number of units that are dispensed. This number is not the total number of units for each individual ingredient.
When submitting real-time claims for compound drugs, pharmacy providers should enter a value of "2" in the compound drug field. This alerts the POS system that the NDCs indicated comprise a single compound drug.
Billing Options When Compound Drug Ingredients Are Not on File
If one or more of the ingredients in a compound drug are not present on the drug file, the provider may choose not to bill the ingredient(s) not on file. The provider should submit the remaining ingredients on the Compound Drug Claim form using the previously defined billing instructions.
If a compound drug has any noncovered ingredients, payment for those ingredients will be denied, but the rest of the ingredients will be covered, assuming other conditions are met.
The BadgerCare Plus Standard Plan, Medicaid, and SeniorCare do not cover compounded medications in dosage forms that have no proven therapeutic effect.
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