The most recent Pulse on Provider Status newsletter covered the following set of frequently asked questions from PSW members. Check them out! If you are interested in receiving future issues of the newsletter, enroll here!
Frequently Asked Questions
Q. Can we bill for a long-acting injectable product using the pharmacist provider's NPI as the rendering provider when the product is being provided to the patient to be administered at the physician's office?
A. Yes, since the product component and administration component are provided by separate entities. Each entity needs to determine whether billing the product through the pharmacy or through the medical benefit is more cost-effective.
Q. Do I need to have a collaborative practice agreement (CPA) established with a physician in order to become a medical provider for Wisconsin Medicaid?
A. No, although there is a question in the WI Medicaid enrollment process that asks providers to attest to whether they ever work under a CPA. There are many services that can be provided and billed for by pharmacist providers without a CPA (e.g., non-vaccine injection administration, education, office visits without ordering labs or prescriptions). Once enrolled, providers are responsible for updating the ForwardHealth Demographic Maintenance Tool when there is a change in CPA status. To enroll as a provider with WI Medicaid, visit the PSW website and scroll down to "Enroll with ForwardHealth as a Provider".
Q. When will I receive reimbursement for medical claims submitted under provider status?
A. DHS 106.04 mandates that all claims be paid within 180 days of receipt, but it is most likely that you will receive payment within 30 days. The timeliness of claims payment is regulated by performance standards, which mandate that a certain percentage of claims are paid within a specified period following receipt of the claim. These standards are as follows: 95% within 30 days, 99% within 90 days, and 100% within 180 days.
Q: Can patients use non-emergency medical transportation (NEMT) to travel to the pharmacy for injections?
A: Yes, traveling to the pharmacy for an injection or other covered provider service is an allowable reason to use NEMT services through ForwardHealth. However, eligibility for rides depends on the patient's coverage.
MTMHealth (formerly Medical Transportation Management) provides NEMT rides for most members enrolled in the following programs who do not have other ways of getting to their covered appointments:
· Wisconsin Medicaid (including IRIS)
· BadgerCare Plus
· BadgerCare Plus Express Enrollment for children and pregnant people
· Tuberculosis-Related Services-Only Benefit
· Family Planning Only Services
How to schedule:
· Patients: Members can schedule rides online or by calling 1-866-907-1493 to confirm eligibility and arrange transportation.
· Pharmacies/Facilities: Pharmacies can also help members schedule rides by using the resources here or by setting up a profile in the Facility Portal.
Q. I would like to submit medical claims to WI ForwardHealth for CLIA-waived lab tests provided in the pharmacy. How do I go about doing this?
A. The pharmacy is required to become an independent lab in order to bill for CLIA-waived lab tests. The following outlines the process along with important reminders about anticipated DHS rules updates.
Before applying to Medicaid to become an Independent Lab, the pharmacy needs to:
1. Get a CLIA-waiver
2. Become Medicare certified by updating your Provider Transaction Access Number (PTAN) on the PECOS site -- this may involve adding an additional taxonomy to the pharmacy's current PTAN
a. It currently costs $730 to bbecome Medicare certified as an independent lab. Medicaid will subsequently waive the separate $730 enrollment fee for enrolling as a Medicaid independent lab provider. (step #4)
b. Medicare enrollment requires the CLIA-waiver process to be completed first.
3. Add the independent lab taxonomy code to the pharmacy's NPI on the NPPES website
a. Verify with your point of sale dispensing system vendor whether they support the override that allows specification of the taxonomy for billing. If the vendor doesn't have this capability, then the pharmacy should apply for a new NPI for the independent lab.
4. THEN, complete the Medicaid independent lab provider application
a. Medicaid application asks for Medicare certification 5-digit #
b. Medicaid application asks for NPI (which now should have an independent lab taxonomy attached or be specific to the independent lab)
5. For billing:
a. Rendering provider = Use NPI (with pharmacy and independent lab provider taxonomies) or separate NPI for independent lab
b. Billing provider = use NPI (with pharmacy and independent lab provider taxonomies) or separate NPI for independent lab
c. POS = 81 (independent lab)
There are plans to update DHS 107.25 according to 2017 WI Act 119. The earliest the ForwardHealth update and rule changes will occur will be in early 2026. The update will clarify that health care providers will be able to provide diagnostic tests without a prescription from a physician and within their scope. They won't be clarifying what constitutes a CLIA-waived diagnostic vs. non-diagnostic test. Independent lab providers will need to make their own internal decision on whether a prescription is needed from a physician for diagnostic tests based on the current DHS 107.25/WI Act 119 language.
Q.
------------------------------
Kari Trapskin PharmD
Pharmacy Society of Wisconsin
Madison WI
608-827-9200
------------------------------