©201 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry ® Illinois Medical Bill Reviewer Training Program Unit 3: Ancillary Services Module 1: Pharmacy Guidelines

2 Illinois Regulation Training - Pharmacy July 2011 Overview Hi! In this module, you will learn about pharmacy guidelines. Pharmacy Reimbursements Drugs and Supplies Then, you will learn how other types of pharmacy services are reimbursed.

3 Illinois Regulation Training - Pharmacy July 2011 Pharmacy Guidelines Key all pharmacy charges as billed. The National Drug Codes (NDCs) are available in the system. If the NDC code is not found in the fee schedule, payment will be recommended at the usual and customary value (at the applicable percentile), or will be recommended for payment at the providers billed charge, whichever is less.

4 Illinois Regulation Training - Pharmacy July 2011 Prescription Reimbursement Prescriptions require a few pieces of information that you can locate on a pharmacy bill. The required information is: NDC number Number of units Billed Charge Date of Service

5 Illinois Regulation Training - Pharmacy July 2011 Drugs and Supplies Supplies and/or materials normally necessary to perform a service are included in the primary procedure or office visit. These include supplies such as: Cotton balls Band-Aids Applied meds/ointments

6 Illinois Regulation Training - Pharmacy July 2011 Drugs and Supplies If the code is not found in the fee schedule, payment will be recommended at the usual and customary value (at the applicable percentile), or will be recommended for payment at the providers billed charge, whichever is less.

7 Illinois Regulation Training - Pharmacy July 2011 Drugs and Supplies Supplies and materials provided by the physician over and above those usually included with the office visit or other service rendered may be charged for separately. There is no fee schedule pricing for drugs or supplies. Pay charges according to U & C. Key as billed. There should be no additional "handling" costs added to the total cost of the item.

8 Illinois Regulation Training - Pharmacy July 2011 Summary Pharmacy Reimbursement Guidelines Reimbursement of Supplies Thats All, Folks!!!