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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.3 Coding : 6.3.4 National Drug Code (NDC) : 6.3.4.3 Drug Rebate Program

6.3.4.3
Texas Medicaid will reimburse providers only for clinician-administered drugs and biologicals whose manufacturers participate in the Centers for Medicare & Medicaid Services (CMS) Drug Rebate Program and that show as active on the CMS list for the date of service the drug is administered.
CMS maintains a list of participating manufacturers and their rebate-eligible drug products, which is updated quarterly on the CMS website. TMHP will republish this list quarterly in a more accessible format.
Refer to:
When providers submit claims for clinician-administered drug procedure codes, they must include the National Drug Code (NDC) of the administered drug as indicated on the drug packaging.
TMHP will deny claims for drug procedure codes under the following circumstances:
To avoid claim denials, providers must speak with the pharmacy or wholesaler with whom they work to ensure the product purchased is on the current CMS list of participating manufacturers and their drugs.
Note:
Texas Medicaid managed care organizations (MCOs) have their own policies and procedures regarding clinician-administered drugs. Providers must contact the client’s MCO for benefit and limitation information.
Providers can find a complete, downloadable list of procedure codes and the corresponding descriptions on the Vendor Drug Program website at www.txvendordrug.com/downloads/CADR/HCPCS-Requiring-Rebateable-NDCs.xls.
Vitamins and minerals procedure codes will be listed on a separate tab of the supplemental file.
TMHP has created a Rebatable National Drug Codes web page to display the quarterly lists published by CMS. Every quarter, after CMS publishes an updated list of rebatable NDCs, TMHP will produce a formatted list with the unnecessary details removed and will add the new list to the web page.
Note:

Texas Medicaid & Healthcare Partnership
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