Cabinet Secretary
Matt Althoff

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Medicaid Provider Pharmacy

Effective November 13, 2017 South Dakota Medicaid will utilize OptumRx to process pharmacy claims and pharmacy prior authorizations under South Dakota Medicaid coverage and benefit rules. Please visit the OptumRx website for prior authorization forms and additional information.

All pharmacy related calls are handled by OptumRx. Member and eligibility questions will continue to be answered by South Dakota Medicaid.  The contact information for OptumRx is listed below:

Help Desk 855.401.4262 Optum RX
FFS Pharmacy Prior Authorization support 855.401.4262 Optum Rx
FFS Pharmacy Prior Authortiztion Fax Number 800.527.0531 Optum Rx
Member and eligibility questions 800.452.7691 SD Medicaid

Information can be found on the South Dakota Medicaid Drug Rebate program.

BIN Number

South Dakota Medicaid’s processor BIN number is 601574. This number has been assigned to the South Dakota Medicaid Program by the American National Standards Institute (ANSI). The BIN number must be included in all NCPDP transactions routed to the South Dakota Medicaid POS system.

PAYER SHEETS

Payer sheets are documents that detail the payer specific claim requirements for pharmacy point of sale claims. Payer Sheet User Guide

NDC NUMBERS

South Dakota Medicaid utilizes Medispan to maintain its drug pricing file. If you are unable to locate a NDC number, please check your Red Book, Blue Book or other nationally recognized publication.

EARLY REFILL OVERRIDES AND DAYS SUPPLY

Overrides of the early refill denial must be medically necessary and consistent with the recipient’s symptoms, diagnosis, condition, or injury. Use of the override process in not for the convenience of the recipient or the provider. Accurate day supply information is required for the early refill alert. Vacation overrides are not allowed.

POINT-OF-SALE (POS) REVERSALS

Pharmacist may retract any claim that has been paid by submitting an NCPDP reversal transaction. Reversals may be used in many circumstances. Examples:

a.

A prescription is not picked up by the patient;


b.


The quantity dispensed is changed or not utilized;


c.


Prospective Drug Utilization Review (ProDUR) information provided by the system as a claim was paid results in a prescription not being dispensed or being modified. If modified, the new claim may be submitted at any time after the reversal; and


d.


An error was made when submitting the claim. A corrected claim may be submitted and processed at any time after the reversal. Generally, a reversal and resubmission can be used in place of the hard copy adjustment form.

DENIED POS CLAIM

If a claim has been denied for any reason, you may rebill via the POS system if you think the claim should be payable, making any needed claim corrections. Example: If the claim is denied because the medical assistance ID number is invalid, correct the ID number and resubmit.

COMPOUND PRESCRIPTIONS

Claims for compound prescriptions can be billed through the POS system. Pharmacy providers will be reimbursed for all covered NDC numbers that correspond with the South Dakota Medicaid drug pricing file. There must be a covered NDC within the compound for the claim to be paid.

OVER-THE-COUNTER DRUG COVERAGE

The Over-the-Counter (OTC) drugs listed below have been recommended by the South Dakota Medicaid Pharmacy and Therapeutics (P&T) Committee for coverage. The coverage of these OTC drugs is contingent on the adoption of rules allowing OTC drug coverage
As with all drugs covered under the South Dakota Medicaid Drug Program only drugs whose labeler has a signed rebate agreement with the Centers for Medicare and Medicaid Services (CMS) and are ordered by a physician via legal prescription will be covered by South Dakota Medicaid. OTC drugs are to be dispensed to Medicaid recipients in the same manner as legend products are dispensed.

  1. non-sedating antihistamines (all dosage forms and strengths available)
  2. pediculicides (e.g. permethrin)

OVERPAYMENTS

In the event that you receive a payment from South Dakota Medicaid in error, or in excess of the amount properly due under the applicable rules and procedures, you must promptly notify South Dakota at 800.452.7691 and arrange for the return of any excess money received. You may also submit a reversal claim.

PAPER CLAIMS

South Dakota Medicaid accepts paper claims, but prefers electronic claims sent via the POS.Paper claims must be billed by using the NCPDP Universal Claim Form. Claims submitted via point-of-sale must follow NCPDP guidelines. Please visit with your software companies if you have questions.