Pharmacies may be enrolled as BCMH providers in accordance with Chapter 4729 of the Ohio Revised Code. Pharmacy services shall be prescribed by a physician approved under rule 3701-43-03 of the Ohio Administrative Code. All providers must complete a BCMH Provider Application Form and sign a BCMH Provider Agreement. If a pharmacy is a subsidiary of a large national pharmacy chain, it may be enrolled simply by calling BCMH and requesting same from provider enrollment.
To obtain provider application materials, contact BCMH Provider Management at (614) 466-1700 or BCMH@odh.ohio.gov.
Prescription medications are included in the service packages for the following eligible diagnoses. All medications must be directly related to the eligible handicapping condition:
· Cleft lip/palate
· Cystic fibrosis
· G.I. conditions
· Heart disease
· Metabolic conditions
· Neuromuscular conditions (including cerebral palsy)
· Pulmonary conditions
· Renal/G.U. conditions
· Seizure disorder
· Serous otitis
· Sickle cell disease
· Thyroid/pituitary conditions
BCMH is obligated to use Ohio Medicaid’s drug formulary for minimum restrictiveness. BCMH does not set pricing for cost of goods, but merely implements Medicaid’s pricing policies. Behavioral health problems and acute conditions are not eligible on the BCMH program. Similarly, medications that treat behavioral health problems (e.g. depression, ADHD) or acute medical conditions (e.g. allergic iritis) are not covered services by the BCMH. Some drugs excluded by Medicaid may be eligible for BCMH coverage.
BCMH does not cover brand-name drugs when a generic equivalent is available. If a therapeutic failure occurs with the generic drug, the BCMH-credentialed physician must prior authorize use of the brand name drug by calling the ACS Technical Call Center at 1-877-518-1545.
Clients with Other Insurance Coverage
It is the responsibility of all pharmacy providers to bill all other available third-party payers prior to billing BCMH. This assures BCMH is the “payer of last resort,” per the BCMH Provider Agreement, the Ohio Revised Code, Chapter 3701 and the Ohio Administrative Code, Chapter 3701-43.
· The Point of Sale system and the BCMH Letter of Approval contain information regarding each client’s private insurance and/or Medicaid status. If a parent states they no longer have insurance, or their insurance carrier has changed, please fax the current information to the attention of the BCMH Third Party Unit (614-728-3616) for follow-up review and correction of records.
· For a child with insurance, a claim without a reasonable amount listed in the third-party liability (TPL) field will be automatically rejected by the online system. This denial indicates insurance must be billed first and the amount insurance is paying must be entered in the TPL field. BCMH has identified a problem with some providers not billing the insurance company and instead listing inaccurate “token” amounts (e.g. one penny or one dollar) so the claim will process. This process is fraudulent. If a provider is found to be fraudulently billing, the provider may be referred to the Attorney General’s office for a compliance investigation.
· Pharmacies must follow proper procedures, including the prior authorization process, and bill Medicaid for pharmaceuticals provided to children who are active on the Medicaid program. It will not be possible to bill BCMH for any medication for any child who is Medicaid active.
Prior Authorization Process
Growth hormone is one drug that requires routine prior authorization. There is, in addition to growth hormone, a small list of other medications that require prior authorization. Pharmacies are notified via a computer message at the time of claim submission for adjudication if a specific drug will require prior authorization. The Ohio Department of Job and Family Services has its own prior authorization form that must be used for children whose pay source is Medicaid.