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Billing Instructions for 340B Drug Claims Submission

Currently, the Department of Community Health (DCH) Medicaid Program uses the Health Resources and Services Administration (HRSA) Medicaid Exclusion file to identify all 340B claims to be removed from the rebate system, thereby avoiding duplicate discounts. Federal law (42 USC 256b(a)(5)(A)(i)) prohibits duplicate discounts – manufacturers are not required to provide a discounted 340B price and a Medicaid drug rebate for the same drug. To prevent duplicate discounts from taking place, the Covered Entity (CE) is required to follow the HRSA rules, and provide HRSA with its Medicaid provider number/National Provider Identifier (NPI) at the time of enrollment. HRSA then lists the covered entity and its Medicaid number/NPI on the Medicaid Exclusion File, which lets states and manufacturers know that drugs purchased under that CE’s Medicaid billing number(s) are not eligible for a Medicaid rebate. 

Additional information on HRSA's Medicaid Exclusion File is available at http://www.hrsa.gov/opa/programrequirements/medicaidexclusion/index.html

Effective April 1, 2017, all 340B Covered Entities are required to bill the Georgia Medicaid Division with a submission clarification code of 20 on Fee-for-Service (FFS) and Care Management Organizations (CMO) outpatient pharmacy claims. 

Additionally, FFS outpatient pharmacy claims will be reimbursed at their submitted 340B actual acquisition cost plus the submitted professional dispensing fee in accordance with the federal law requirements in §447.518(a)(2). The provisions of this rule related to pharmacy payments do not apply to MCO payment or reimbursement methodologies, including MCO providers participating in the 340B program.

Please Note: Contract pharmacies are not allowed to bill DCH for 340B-purchased drugs.

Claims with dates of service on or after April 1, 2017, may be subject to audits to confirm compliance with our 340B policy.  CE’s should decide if they will continue to participate in the 340B program for Georgia Medicaid members and notify HRSA by the March 15, 2017, deadline.

CE’s that are in compliance with our 340B policy are encouraged to start submitting their claims on or after April 1st using the following information for FFS claims:

Claims submitted via the NCPDP format to the Pharmacy Benefit Manager (PBM) must include the Submission Clarification Code 20 and the National Drug Code (NDC). CE’s must bill the professional dispensing fee in addition to the actual acquisition cost of the drug. 

If you have any questions regarding Georgia Medicaid’s policy on the 340B program, please contact the Department by e-mail at 340B@dch.ga.gov.

Thank you for your continued service and participation in the Georgia Medicaid & PeachCare for Kids Programs.

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Last Updated On: 1/10/2017