AB 1114 Pharmacist Services, Frequently Asked Questions

 1. Who is an eligible recipient of this service?

To be an eligible recipient of this service, the patient’s Medi-Cal enrollment must be active on the date of service. The provider must verify that the patient is eligible to receive Medi-Cal benefits. Medi-Cal’s Automated Eligibility Verification System (AEVS) is a great resource.

2. Who is qualified as a Billing provider?

The requirement is that a claim for payment of pharmacist services may only be submitted by a Medi-Cal enrolled pharmacy provider.  Note that it is the PHARMACY that has to submit the claim. Not the individual pharmacist.

3. How does one become an eligible Furnishing pharmacist for the purposes of AB 1114?

It is required that the furnishing pharmacists must enroll as an  ordering, referring, and prescribing (ORP) providers under Medi-Cal prior to rendering pharmacist services. This means that for the reimbursement of these services, the pharmacist must be an approved ORP provider.
Applications are available on the Medi-Cal website.

4. What are the Eligible Services?

Eligible services must be provided in accordance with the requirements and protocols outlined in the Business and Professions Code (BPC) and California Code of Regulations (CCR). They are as follows:
 
 

5.  What forms must pharmacy providers use for billing these services?

  • Pharmacies must bill Pharmacist Services on a CMS-1500 health claim form or ASC X12N 837P v.5010 transaction. 
  • Providers may not submit claims on the Pharmacy Claim Form (30-1) or Compound Drug Pharmacy Claim Form (30-4) when billing for these services.
  • Professional service claims submitted on a 30-1, 30-4, or via the NCPDP standard will be denied.
 

6. What are Medi-Cal’s authorized pharmacist services billing codes?

The following CPT codes should be used by the pharmacy to bill for the corresponding services on the CMS-1500 health claim form or ASC X12N 837P v.5010 transaction. 
 
​CPT Code ​Description ​Services
99201​ New Patient​
  • Furnishing naloxone hydrochloride
  • Furnishing self-administered hormonal contraception
  • Initiating and administering any vaccination
  • Furnishing nicotine replacement products
  • Furnishing travel medications​
​99212 ​Established Patient
  • ​Furnishing naloxone hydrochloride
  • Furnishing self-administered hormonal contraception
  • Initiating and administering any vaccination
  • Furnishing nicotine replacement products
  • Furnishing travel medications
​90471 ​Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
  • ​Administering any vaccination
 
 

 7. How is reimbursement for pharmacist services defined/calculated?

 Welfare and Institution Code Section 14132.968 (3), is the statutory authority that allows reimbursement of pharmacist services under Medi-Cal.  It also established the rate of reimbursement for pharmacist services at 85 percent of the fee schedule for physician services.
 
Since the physician service fee schedule is subject to change, Pharmacy Benefits Division uses the current fee schedule to calculate the pharmacist services rates. The final reimbursement rate is subject to any applicable legislative reductions and supplemental payments. Currently two legislations impact the reimbursement of pharmacist services. These are Assembly Bill 97(Chapter 3, Statutes of 2011) and Assembly Bill 120 (Stats. 2017, Ch. 22, § 3, Item 4260-101-3305).
 
Assembly Bill 120 allows the appropriation of Proposition 56 funds in the 2017-18 state fiscal year for specified DHCS supplemental payment expenditures, while Assembly Bill 97 requires DHCS to implement 10% provider payment reductions to most categories of services in Medi-Cal fee-for-service (FFS) program.
 
The California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56) increased the excise tax rate on cigarettes and tobacco products for purposes of funding specified expenditures, including funding for existing programs administered by DHCS. Information on Prop 56 and current appropriations can be found on the Prop 56 webpage.
 
Medi-Cal enrolled providers can look up the physician rate (base rate, does not include any reductions or supplemental payments) on the  Medi-Cal webpage under the transaction services tab. Once logged in, click on the Provider Automated Services tab then Procedure Code inquiry tab. Once open enter the desired CPT billing code and submit the request to obtain the rate.
 

8. Frequency of billing restrictions on 99212.

Pharmacists may bill CPT code 99212 for each covered pharmacist service rendered in a visit.  This code is currently restricted to six visits in 90 days per patient. This frequency restriction may be exceeded with medical justification.  Providers must submit the medical justification, with the original claim, when an evaluation and management visit with an established patient exceeds six visits in 90 days.  Providers must document that the patient’s acute or chronic condition requires frequent visits in order to monitor their condition with the goal of decreasing hospitalizations. A Treatment Authorization Request (TAR) is not required.
 

9. Since the registration is by pharmacy and not pharmacist, how will pharmacists working in the medical clinic where there is no pharmacy be able to bill for services?

Welfare and Institutions Code, Section 14132.968(c), does not establish the authority for DHCS to reimburse a pharmacist provider directly. DHCS recommends that pharmacists who currently work within a collaborative practice agreement continue to do so. Pharmacists working in collaborative practice agreements scope of services generally exceeds what is permitted within the law. For example, in cases of pharmacist-run anticoagulation clinics, lipid clinics or hypertension clinics, DHCS does not currently have legislative or State Plan Amendment (SPA) authority to include pharmacists as a reimbursable provider type.
 

10. Are rules for medical chart/record keeping the same for these furnishing pharmacists as for other providers in reference to CPT codes 99201 and 99212?

Medical record keeping should be consistent with California statutes and regulations governing the ability of a pharmacist to furnish mediations in California along with standards of practice for medical record keeping by pharmacists.
 

11. Would rendering pharmacists need to do History and Physical (H&P), full assessments, say for CPT 99201 and keep the medical records for that?

A pharmacist may only provide services within their scope of practice. Medical record keeping should be consistent with California statute and regulation governing the ability of a pharmacist to furnish mediations in California along with standards of practice of medical record keeping for pharmacists.
 

12. Can the Department confirm that the Place of Service code is a 2-digit code?

A two-digit national Place of Service code is placed in the unshaded area of Box 24B, of the CMS-1500 form, indicating where the service was rendered.
 
The national Place of Service codes for professional claims is available on Center for Medicare and Medicaid Services (CMS) website. Medi-Cal also lists the codes on page 16 in CMS-1500 Completion section (cms comp) in the Part 2- General Medicine Medi-Cal Provider Manual. 
 
 Image of NCPDP Pharmacy Claim Form 30-1, Item #24-B.
 

13. Can the drug administration fee (CPT code 90471) be added to the drug cost and submitted as a bundled payment?

Medi-Cal enrolled pharmacies must submit drug claims pursuant to current DHCS policies. Current policy does not allow for a bundled payment on a pharmacy-billed drug transaction.
 
The pharmacist service must be billed separately from the drug component. 
 
An enrolled pharmacy must submit the claim for pharmacist services on either the CMS-1500 health claim form or ASC X12N 837P v.5010 transaction.  Claims submitted on the NCPDP, Pharmacy Claim Form (30-1) or Compound Drug Pharmacy Claim Form (30-4) will be denied.
 

14. Does "furnishing for self admin" = CPT code 90471 administration fee?

The CPT code 90471-administration fee may only be billed by a pharmacy when a pharmacist within the pharmacy administers a vaccine via a method described in the definition of the code. Immunizations administered by the patient or by an outside entity are not billable by the pharmacy.
 
​CPT Code ​Description
​90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections)​; 1 vaccine (single or combination vaccine/toxoid)
  
  

15. Will the pharmacist be able to bill for the CPT/J code of the dispensed medication on the same form as the service or does FFS still rely on them to bill through NCPDP pharmacy billing?

The enrolled pharmacy must bill drug claims via the current authorized standards in compliance with Medi-Cal billing policy. For the vast majority of pharmacy billed drug claims this includes NCPDP D.0, Pharmacy Claim Form (30-1) or Compound Drug Pharmacy Claim Form     (30-4).
 
An enrolled pharmacy must submit the claim for pharmacist services on either the CMS-1500 health claim form or ASC X12N 837P v.5010 transaction.  Claims submitted on the NCPDP, Pharmacy Claim Form (30-1) or Compound Drug Pharmacy Claim Form (30-4) will be denied.
 

16. How long does the Furnishing Pharmacist Application take to be processed and approved by Department of Health Care Services (DHCS)?

The statutory timeframe for processing an ORP application is 180 days.
 

17. Can the pharmacist enroll via PAVE?

Yes, ORP applications must be submitted in PAVE.
 

18. How does having Other Health Coverage apply to this benefit?

Providers should follow existing Medi-Cal billing practices. A recipient eligible for Medi-Cal may also have Other Health Coverage (OHC).  In most circumstances, OHC must be billed prior to billing Medi-Cal. For example, if a recipient has a commercial insurance plan that will not cover pharmacy services, providers should bill the commercial insurance plan, receive a denial and then bill Medi-Cal with the OHC denial. A recipient is required to utilize their OHC prior to Medi-Cal when the same service is available under the recipient’s private health coverage.
 

19.  How does Share of Cost apply to this benefit?

Providers should follow existing Medi-Cal billing practices when billing for services rendered to recipients with a Share of Cost (SOC). Some Medi-Cal recipients must pay, or agree to pay, a monthly dollar amount toward their medical expenses before they qualify for Medi-Cal benefits.  This dollar amount is called Share of Cost (SOC). This is similar to a private insurance plan’s out-of-pocket deductible. Please note that for pharmacy services, providers cannot clear SOC utilizing NCPDP or 30-1 transactions.
 

20. What are the statutory authorities for these services?

All pharmacists who render these services must follow the protocols in accordance with the requirements of the Business and Professions Code and California Code of Regulations, including the training, provider notifications and all record keeping as specified in the protocols and in pharmacists’ scope of practice.
 

21. What documentation must be kept on site for these services?

Documentation of these services is a requirement. Medical record keeping should be consistent with California statute and regulation governing the ability of a pharmacist to furnish mediations in California along with standards of practice for medical record keeping by pharmacists.
 
The medical record documentation must record the patient’s applicable health history including pertinent past and present illnesses, self-screening questionnaires, tests, treatments and outcomes.   This documentation is a legal verification of the care provided and should be complete, legible and concise.  At a minimum, the records must include the following:
 
  • Regulation required questionnaire.
  • Reason for encounter.
  • Appropriateness of therapeutic services provided.
  • Applicable test results (blood pressure/pulse).
  • Recipient’s relevant medical history.
  • Site of service.
  • Total time spent with recipient and time spent on counseling, if applicable.
  • Date, time of service and identity of pharmacist providing the service.
  • Action taken as a result of the encounter.

 

 22. What training is available for the billing methods required for these services?

The Medi-Cal Provider Outreach and Education team are available to train and assist providers who may need training on Medi-Cal claims submission. They offer provider training seminars and webinars for basic and advanced billing for all provider types. Seminars are held throughout California and have billing assistance service at no cost at the Claims Assistance Room (CAR).
 
The Medi-Cal Provider Training Workbooks are available for download and for use at the Medi-Cal provider seminars.
 
Medi-Cal Learning Portal (MLP) is the easy-to-use, one-stop learning center for Medi-Cal billers and providers.
 
For more information, call the Telephone Service Center (TSC) at 1-800-541-5555.
 

23. For the purposes of this benefit, what are the definitions of New versus Established patients?

New Patient: One who has not received any professional service from the pharmacist or pharmacy within the past three years. If a new patient visit has been paid, any subsequent claim for a new patient service by the same provider, for the same recipient received within three years will be paid at the level of the comparable established patient procedure.
 
Established Patient: One who has received applicable professional service from a pharmacy location within the past three years.
 
 
 
 
 
Last modified date: 5/9/2019 2:01 PM