Guidance History

Brief Issue Description

This guidance specifies the state's reporting of the professional dispensing fee to T-MSIS. This document outlines the challenges to reporting the professional dispensing fee and provides recommendations for reporting it to the Pharmacy Claim files using the data element DISPENSE-FEE (CRX141).

Background Discussion

Context

According to State health official letter #16-001^[1], the professional dispensing fee should "reflect the pharmacists' professional services and costs to dispense a drug to a Medicaid beneficiary". The T-MSIS data dictionary defines dispensing fee as the "charge to cover the cost of dispensing the prescription". The professional dispensing fee applies to all drugs except for those reimbursed based on a pharmacy’s usual and customary charges. Each state has their own methodology to calculate the professional dispensing fee. Professional dispensing fee methodologies are defined by Medicaid state plan amendments. States can use various types of tiers to calculate the professional dispensing fees, such as using different fees for generic versus brand name drugs, or for drugs dispensed in urban or rural counties. States may use a separate methodology to calculate professional dispensing fees for 340B drugs^[2] and some specialty drugs.

Current professional dispensing fee rates can be accessed at medicaid.gov^[3]. The professional dispensing fee plus the ingredient costs represent the two main charges paid by Medicaid on an NCPDP transactions.

Challenges

When pharmacy claims are billed to Medicaid from point of sale systems on the NCPDP form, the ingredient cost submitted (NCPDP field 409-D9), the dispensing fee submitted (412-DC), incentive amount submitted (438-E3), other amount claimed submitted (480-H9), flat sales tax amount submitted (481-HA), and percentage sales tax amount submitted (482-GE) minus the patient pay amount submitted (433-DX) and other paid amount submitted (431-DV) should sum to the gross amount due (430-DU)^[4]. The NCPDP also contains fields for the dispensing fee paid (507-F7), ingredient cost paid (506-F6), and total amount paid (509-F9). Many of these fields do not clearly map to any T-MSIS data element, or appear to map to multiple data elements. It is not clear whether the professional dispensing fee field in T-MSIS reflects the dispensing fee paid field from the NCPDP, or the dispensing fee submitted field. The resulting confusion has implications on T-MSIS header and line billed amounts and paid amounts. Whether the value reflects a billed amount or paid amount also impacts whether the state pulls the value from the submitted claim form or the response form. Additionally, when pharmacy benefits are provided through managed care, encounters are submitted by pharmacy benefit managers instead of the state.

In addition to challenges mapping the professional dispensing fee to T-MSIS, some providers will not report this value on the claim forms. Providers billing usual and customary charges do not incorporate professional dispensing fees into the amounts charged for a prescription or drug. Usual and customary charges represent the actual cost paid by consumers at the point of sale, and can be set by individual providers. Providers’ usual and customary charges may not include or reflect the full amounts allowed for ingredient costs. In this case, the provider’s claim will not include the professional dispensing fee.

Guidance

The following provides a crosswalk between the fields used in the NCPDP prescription and service pricing formula^[4] and corresponding T-MSIS data elements.

As specified in the T-MSIS data dictionary, DISPENSE-FEE reflects the amount billed by the provider towards the professional dispensing fee. If the provider does not break out the professional dispensing fee on the NCPDP transaction, this field should be left blank in T-MSIS. There is currently no specific field in T-MSIS to capture either the professional dispensing fee amount paid, or the amount billed or paid towards ingredient costs.

Crosswalk of Pharmacy Dispenser Data Elements

There are two fields on the NCPDP form that capture pharmacy dispenser information: Service provider ID (NCPDP 201-B1) and Provider ID (NCPDP 444-E9). Provider ID (NCPDP 444-E9) is not required on most pharmacy claims. While we do not expect this field to be frequently populated, where this is populated it should be mapped to T-MSIS. Service provider ID (NCPDP 201-B1) is required on most pharmacy claims and we expect it to be mapped to T-MSIS. A crosswalk of provider types from pharmacy claims forms to T-MSIS can be found in the Data Dictionary Appendix P.07 Table F.

[1] State health official letter #16-001.

[2] The 340B drug pricing program is an initiative by the Health Resources & Services Administration that arranges for manufacturers participating in Medicaid to provide outpatient drugs to covered entities at reduced prices.

[3] Professional dispensing fees and ingredient cost rates.

[4] National Council for Prescription Drug Programs. Telecommunication Version D and Above Questions, Answers and Editorial Updates. Version 50.0. August 2020.