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Forward Health released a new ForwardHealth Update on Friday, June 14, providing important details related to the July 1, 2024 launch of pharmacist provider medical billing. Effective for dates of service (DOS) on and after July 1, 2024, pharmacists enrolled with ForwardHealth as a provider under 2021 Wisconsin Act 98 may begin to provide and submit claims for covered services. Please review the content in its entirety. Here are the highlights.
1. Collaborative Practice Agreement (CPA) Policy:
The Update clarifies the overarching policy that both the physician and pharmacist involved in a CPA must be enrolled in ForwardHealth. Additionally, requirements and recommendations are provided for what is contained in a CPA. A legislative hearing regarding these rules is forthcoming.
2. Clinical Laboratory Improvement Amendments (CLIA):
Point-of-care testing in the pharmacy setting is CLIA-waived. The Update details that there are no testing personnel requirements for pharmacist providers who perform CLIA-waived testing since any pharmacist can perform CLIA-waived testing. Information about how to pursue CLIA certification for a practice location is provided.
3. General Policy:
The Update notes pharmacist providers are required to follow all ForwardHealth policies and where to find them in the Online Handbook.
4. Covered Medical Services:
The Update outlines that enrolled pharmacist providers can render and/or bill for covered medical services. Covered services, codes, and reimbursement rates will be included in the maximum allowable fee schedule. Examples of covered services listed include (but are not limited to) non-vaccine drug administration, chronic disease state management, member education and training, and physician-delegated services via a CPA.
The list of covered CPT codes is accessible to PSW members on the PSW website.
5. Reimbursement for Covered Medical Services:
Reimbursement for services provided by a pharmacist will be made at the lesser of usual and customary charge or no more than 90 percent of the physician fee for that procedure, except for immunization injections, HealthCheck visits, and select diagnostic procedures, which are paid at the physician fee.
6. Claim Submission:
Providers are responsible for the accuracy, truthfulness, and completeness of all claims submitted by the provider, an outside billing service, or a clearinghouse. Claims received without valid diagnosis codes, revenue codes, and HCPCS, HIPPS, or CPT codes will be denied; prior authorization requests received without valid codes will be returned to the provider. Providers should refer to current national coding and billing manuals for information on valid code sets. Claims must be billed using the 1500 Health Insurance Claim Form or the electronic 837 Health Care Claim: Professional transaction for professional claims.
Pharmacists should review the training on electronic claims submission, which includes submitting claims through the portal. The training is linked here. In addition, Medicaid provider services and Medicaid professional field representatives can provide technical assistance regarding claims submission. Information on contacting a field representative can be found on the provider page of the ForwardHealth portal.
7. Pharmacy Provider Policies Unaffected:
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The Medication Therapy Management (MTM) program is not changing due to WI Act 98. A separate office visit should not be billed for a covered MTM service visit. See the Wisconsin Pharmacy Quality Collaborative PSW link.
- Wisconsin Medicaid and BadgerCare Plus fee-for-service reimburses pharmacists or pharmacies for vaccine services provided in a pharmacy for children (through the VFC program) and adult members, even if the member is enrolled in a state-contracted managed care organization.
- Billing for vaccine services is not changing as a result of Act 98. Providers should continue to submit professional claims for vaccines administered to Wisconsin Medicaid and BadgerCare Plus members.
8. Additional Information for Pharmacist Providers
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Dual Eligible Members: Refer to the Member Payment for Covered Services topic (#86) for more information.
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Federally Qualified Health Centers (FQHCs): An FQHC may bill for covered medical services provided by the FQHC's pharmacist if the billing provider is the FQHC itself and the rendering provider is the pharmacist. However, if a patient vits a physician and a pharmacist on a single day, those visits will be classified as a single encounter for billing purposes. If an FQHC adds pharmacy services to their practice, they may qualify for a change in scope that would increase their Prospective Payment System (PPS) rate.
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Rural Health Clinics (RHCs): ForwardHealth now includes pharmacists as providers at RHCs. The revised voluntary form and instructions can be found on the Forms page of the ForwardHealth Portal.
9. Documentation Retention:
The Update reminds providers to follow the documentation retention requirements per Wis. Admin. Code § DHS 106.02(9). Providers must produce or submit documentation, or both, to DHS upon request. Per Wis. Stat. § 49.45(3)(f), providers of services shall maintain records as required by DHS to verify provider claims for reimbursement. DHS may audit such records to verify the actual provision of services and the appropriateness and accuracy of claims. DHS may deny or recoup payment for services that fail to meet these requirements. Refusal to produce documentation may result in denial of submitted claims, recoupment of paid claims, application of intermediate sanctions, or termination from the Medicaid program.
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