AGENCY FOR HEALTH CARE ADMINISTRATION
MedicaidRULE NO.: RULE TITLE:
59G-4.250: Prescribed Drug ServicesNOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 38, No. 5, February 3, 2012 issue of the Florida Administrative Weekly.
The following changes are made to the proposed rule.
59G-4.250 Prescribed Drug Services.
(3) The following forms are incorporated by reference: MPDS2012-1-22, Recipient Lock-in Letter Form, January 2012; MPDS2012-1-23, Request for Reconsideration Form, January 2012; MPDS2012-1-24, Request for Fair Hearing Form, January 2012; MPDS2012-1-25, Request to Change Lock-in Pharmacy, January 2012; and MPDS2012-1-26, Prescribed Drugs Lock-in Referral Form, January 2012. These forms may be accessed at http://ahca.myflorida.com/Medicaid/Prescribed_Drug/lockin.shtml.
The following changes have been made to the Florida Medicaid Prescribed Drug Services coverage, Limitations and Reimbursement Handbook.
Page 1-4 Health Maintenance Organizations (HMO): Prescribed Drug Services.
Second paragraph is changed to read:
A Medicaid HMO is required to cover any product that is required to be covered under the fee-for-service Medicaid program as specified in section 1927 of Title XIX of the Social Security Act. If a product meets the definition of a covered service under that section there must be a provision to make it available through the HMO and through fee-for-service.
Page 1-7 Provider Enrollment, continued: Effective Date of Enrollment.
First bullet is changed to read:
With respect to providers who must be licensed, upon approval of the provider application, the enrollment effective date shall be the date the agency receives the complete provider application.
Page 1-15 Recordkeeping Requirements, continued: Requirements for Prescription Records.
Paragraph is changed to read:
For other information concerning prescription records, see Chapters 465 and 893, F.S., and Chapter 64B-16, F.A.C., not incorporated herein.
Page 1-19 Recipient Over-Utilization or Fraud, continued: Fair Hearing.
First paragraph is changed to read:
Upon determination by AHCA that a recipient will be assigned to a single pharmacy for services, the recipient will be notified by letter. The letter includes information about the recipient’s opportunity for a fair hearing. The right of notice and the opportunity for a fair hearing applies to both the original lock-in and any lock-in occurring from future recipient actions.
Page 2-10 Service Limitations, continued: Recipient Information about Rejected or Denied Prescriptions.
First paragraph is changed to read:
Medicaid provider pharmacies are required to exhaust all avenues available to them in order to fill a valid prescription. For other information regarding rejected or denied prescriptions, see Rule 59G-4.255, F.A.C., not incorporated herein.
Second paragraph is deleted.
Third paragraph is deleted
Page 4-2 Special Billing for Medically Needy Recipients: Receiving a CF-ES Form 2902. Section is deleted
Page 5-5 Title now reads: Captured Claim Response Deleted
New paragraph is created to read:
Effective 1/1/2012, point of sale claims will no longer “Capture” pending determination of Medicaid eligibility. If a submitted prescription claim denies because the recipient does not appear to be Medicaid eligible, the claim will be denied.
Remaining paragraphs are deleted.
