STATUTORYREVISIONSTOREIMBURSEMENTOFPRACTITIONER
DISPENSEDREPACKAGEDMEDICATION
CS/SB662(Ch.2013Ͳ131,LawsOfFlorida)EffectiveJuly1,2013
DISCLAIMER
ThefollowingseriesofquestionsandanswersisprovidedbytheDivisionofWorkers’
Compensationforinformationalpurposesonly,withagoaltogenerallyassiststakeholdersin
understandingrecentamendmentstosection440.13(12)(c),FloridaStatutes.Totheextentany
oftheinformationcontainedinthequestionsandanswersmaynotbesupportedbytheplain
meaningoftheamendedstatute,thatinformationisnottobeconstruedasaDepartmentof
FinancialServicesstatementofgeneralapplicabilitythatimplements,interprets,orprescribes
laworpolicyordescribestheprocedureorpracticerequirementsoftheDepartmentof
FinancialServices.TheDepartmentofFinancialServicesisintheprocessofinitiating
rulemakingproceedingsregardingtherecentamendmentstosection440.13(12)(c),Florida
Statutes,whichwillbetheprocessthroughwhichanystatementofgeneralapplicabilitythat
implements,interprets,orprescribessection440.13(12)(c),FloridaStatutesasamended,or
describesprocedureorpracticerequirementsoftheDepartmentofFinancialServicesregarding
theamendedstatute,willbepromulgated.
FREQUENTLYASKEDQUESTIONS
1.
Q: WhendothechangestoSection440.13(12)(c),FloridaStatutes
(F.S.)takeeffect?
A: ThechangestoSection440.13(12)(c),F.S.becomeeffectiveJuly
1,2013.Thenewlawwillapplytoanyrepackaged 1 prescription
medicationsdispensedbyapractitioneronorafterJuly1,2013.
1
Section440.13(12)(c),FloridaStatutes,usestheterm“repackagedorrelabeled”.WhenevertheDivisionusesthe
term“repackaged”or“repack”,itisareferencetothestatutoryterm“repackagedorrelabeled”.
Thestatuteusestheterm“prescriptionmedication”.Referencesto“medication”inthisdocumentaremeantto
beto“prescriptionmedication”anddonotincludeOverͲtheͲCounter(OTC)medication.Thestatutealsousesthe
terms“medication”and“drug”interchangeably.Theyarealsousedinterchangeablyinthisdocument.
2.
Q: Whichformshouldadispensingpractitionerusewhenbillingfor
dispensedmedications?
A: Theproperformforbillingpractitionerdispensedmedicationsis
theHealthProviderClaimForm/CMSͲ1500alsoknownasthe
DFSͲF5ͲDWCͲ9.ItmaybefoundontheCentersforMedicare
andMedicaidServiceswebsiteorthroughalinkontheDivision’s
webpageunderRuleChapter69LͲ7.
3.
Q:WhichNationalDrugCode(NDC)numbershouldbeusedwhen
billingpractitionerdispensedrepackagedmedications?
A: Section440.13(12)(c),F.S.,statesthatpharmaceuticalclaimsfor
repackagedmustincludetheoriginalmanufacturer’sNDC.
However,thisalonewillnotprovidealltheinformationneeded
bythecarriertoaccomplishcorrectreimbursement.Thecarrier
willalsoneedthedispensed,repackagedNDCtoknowthatthe
billedmedicationshouldbereimbursedattheappropriaterate.
4.
Q:IstherepackagedNDC(i.e.,thedispensedNDC)requiredtobe
onthebill?
A: PursuanttotheFloridaWorkers’CompensationMedicalServices
Billing,FilingandReportingRule,69LͲ7.602,F.A.C.,theprovider
isrequiredtoidentifythedispensedNDConthebill.So,ifthe
practitionerdispensedarepackagedmedication,itisrequired
onthebill.Sincethelawchangerequiresthattheoriginal
manufacturer’sNDCbeincludedintheclaim,boththeoriginal
andrepackagedNDCnowmustbedocumentedbytheprovider.
TheDivisionbelievesthatthebestpracticeinthisregardisfor
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theprovidertobillbothNDCsintheupperlevelofthebilled
line.Inotherwords,theproviderisencouragedtobillboth
NDCsonthesameline.Ifacarrierwishestoverifytheoriginal
manufacturer’sNDCorhaveitdocumentedinaparticularway,
theruleallowsacarriertorequestinwriting,atthetimeof
authorization,thespecificdocumentationnecessaryto
accomplishreimbursement.
5.
Q:Mayabilledlineitemforarepackagedmedicationbedenied,
disallowed,orreturnedifthedispensingpractitionerneglected
toincludetheNDCoftheoriginalmanufacturer?
A: Itisnotpropertodeny 2 anentirebillorsinglelineitemifthe
NationalDrugCodeoftheoriginalmanufacturerwasomitted.
Thelineiteminquestionmaybedisallowed,usingEOBRCode
66todisallowthelineforamissingNDCNumber;however,a
carriermayobtaintheomittedNDCNumberandreimburseit
usingEOBRCode80.PleasenotethatTheDivisionplanstoadd
EOBRCodesspecifictorepackagedmedicationthatthecarriers
andtheirvendorsmaybeginusingonavoluntarybasistoreport
theiradjustmentofrepackagedmedicationreimbursement.
EditsintheMedicalDataSystem(MDS)wouldbeinstitutedto
allowthevoluntaryuseofthesenewcodes.
AcarriermayuseSection69LͲ7.602(5)(j),FloridaAdministrative
Code(F.A.C.),toreturnabillthatomitstheoriginal
manufacturer’sNDC.TheDivisionencouragesthatacarrier
2
Theterms“denial”,“deny”or“denied”representsacontentionthattheclaimorbenefitisnotcompensableand
thatthecarrieriswithoutliability.Theterms“disallow”or“disallowed”representsacontentionthattheclaimor
benefitisnotreimbursableforsomestatedreason,butthatcompensabilityisnotatissue.
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disallowsoradjustsbilledlineitemsusingtheEOBRCodeslisted
in69LͲ7.602(5)(o),F.A.C.ratherthanreturnthebill.
6.
Q:Whatifapractitionerdisagreeswiththeamount(s)reimbursed
bythecarrierorentityactingonbehalfofthecarrier?
A: ThepractitionermayfileaPetitionforReimbursementDispute
withtheDivisionofWorkers’Compensationwithin45daysof
theirreceiptofnoticeofdisallowanceoradjustmentofpayment
(i.e.,EOBR).DetailsmaybefoundontheDivision'swebsite.
7.
Q:Whatistheproperreimbursementrateforbilledpractitioner
dispensedƌĞƉĂĐŬĂŐĞĚmedications?
A: Absentavalidcontractdirectlybetweentheemployerorcarrier,
or its representative, and the provider, or its representative,
seeking reimbursement, section 440.13(12)(c), F.S., states that
reimbursement shall be 112.5 percent of the original
manufacturer’s average wholesale price (AWP), plus $8.00 for
the dispensing fee.
8.
Q:Whenmayacarrierreimbursepractitionerdispensed
medicationsbasedonacontractrate?
A:Reimbursement under a contract is appropriate where there
is a valid contract governing reimbursement, and the
contract is directly between the employer or carrier, or its
representative, and the provider, or its representative.
However, to reimburse under the contract, the amount to
be reimbursed must be less than the fee schedule
amount. Reimbursement based on third-party contracts
was repealed by the law change.
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9.
Q:Whatdoesaveragewholesaleprice,inregardstorepackaged
prescriptionmedicationsdispensedbyapractitioner,mean?
A: Pursuanttosection440.13(12)(c),F.S.,theAWPmeanstheperͲ
unitaveragewholesaleprice,setbytheoriginalmanufacturerof
theunderlyingdrugdispensedbythepractitioner,aspublished
intheMediͲSpanMasterDrugDatabase.
10. Q:ShouldabillingpractitioneruseCPTcode99070whenbillingfor
dispensingfees?
A: No,thedispensingfeeshouldbeincludedinthechargeforthe
billedline.ItisabillingerrortouseCPTcode99070for
dispensingfees.
11. Q: Whatifabillingpractitionerneglectstolisttheoriginal
manufacturer’sNDContheDFSͲF5ͲDWCͲ9?
A: Thepractitionerisrequiredtoincludetheoriginal
manufacturer’sNDCintheclaimforreimbursementof
repackagedpharmaceuticals.Thestatutedoesnotspecifyhow
theprovideristoincludethisinformation.TheDivisionbelieves
thatthebestpracticeinthisregardisfortheprovidertobill
bothNDCsintheupperlevelofthebilledline.Inotherwords,
theproviderisencouragedtobillbothNDCsonthesameline.If
acarrierwishestoverifytheoriginalmanufacturer’sNDCor
haveitdocumentedinaparticularway,theruleallowsacarrier
torequestinwriting,atthetimeofauthorization,thespecific
documentationnecessarytoaccomplishreimbursement.
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Iftheoriginalmanufacturer’sNDCisnotdocumentedinanyway
Thecarrierhasthreeoptions:1)itmaycontacttheproviderto
obtainthemissinginformationandpaytheitemusingEOBR
code80,2)itmaydisallowthebilledlinebecauseoftheomitted
originalmanufacturer’sNDCusingEOBRcode66,or3)itmay
returnthebillunderrule69LͲ7.602(5)(j)5.,F.A.C.,onaccountof
requiredinformationthatismissing.
12. Q: Howlongdoesacarrierhavetoreimburseapractitionerfor
dispensedmedications?
A: PerSection440.20(2)(b),F.S.,acarriermustpay,disallow,or
denyallbilledlineitemswith45calendardaysafterthecarrier’s
receiptofthebill.Carrierincludesanyentityactingonbehalfof
thecarrier.
13. Q: Isapractitionerallowedtodispenserepackagedprescription
medications,ormustaworkers’compensationpatientobtain
medicationsthroughapharmacy?
A: Section465.0276,F.S.allowsapractitionertodispense
repackagedprescriptionmedicationstoaworkers’
compensationpatient.
14. Q: WilltheMedicalEDIImplementationGuide(MEIG)beupdated
toincludetheadditionalinstructions?
A: AnupdatetotheMEIGisunderconsideration.TheDivision
planstoaddEOBRCodesspecifictorepackagedmedicationthat
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thecarriersandtheirvendorsmaybeginusingonavoluntary
basistoreporttheiradjustmentofrepackagedmedication
reimbursement.EditsintheMedicalDataSystem(MDS)would
beinstitutedtoallowthevoluntaryuseofthesenewcodes.The
Divisionisconsideringrulechangestorequiretheuseofthese
soontobeavailableEOBRcodes.TheMEIGwouldbechanged
toincludethesenewEOBRcodesintheappropriateappendix
oncetheyarerequiredforuseinreimbursementandreporting.
TheDivisionisalsoconsideringrulechangesthatwouldincrease
theamountofdatacollectedaboutmedicationreimbursement
(e.g.,tocollecttherepackagedNDC,inadditiontothepaid
NDC).Suchchangeswouldrequireachangeinlayoutoftheflat
fileusedbycarriersandtheirvendorstoreportmedicalbill
reimbursements.Thisproposalwouldresultinthe
implementationofa“RevisionF”oftheflatfilereportingformat
astheadditionofanewfieldtothefilelayoutwouldbe
required.
15. Q: Thenewstatuterequiresthatapractitionershallnotpossess
medicationunlessthepractitionerhasmadepaymentwithin60
daysofreceivingthemedicationsfromthedistributor.Howwill
thisbehandled?
A: TheDivisionisstillreviewingthemeaningandimpactofthis
provision.Anyinterpretationofthisstatutewouldlikelyrequire
rulemaking.Inthemeantime,anyoneconcernedabouttheir
obligationsunderthisstatutorychangeshouldconsultprivate
legalcounsel.
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16. Q: StartingJuly1,2013,whichNDCnumbershouldbereportedto
theDivisionviaMedicalEDIwhenreportingreimbursementsfor
practitionerdispensedrepackagedmedication?
A: Thecarrier,ortheirvendor,shouldcontinuetoreportthe
reimbursedNDCnumber(i.e.,theoriginalmanufacturer’sNDC).
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