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Changes in Pharmacy Billing for Influenza Vaccine — Effective October 17, 2011

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Effective Date:

All Prescribing Providers, Pharmacists, and Managed Care Organizations (MCOs) Participating in the Virginia Medical Assistance Programs
Cynthia B. Jones, Director Department of Medical Assistance Services (DMAS)


The purpose of this memorandum is to inform providers that DMAS will begin reimbursing pharmacies through the Pharmacy Point of Sale (POS) claims processing system for influenza vaccine, effective October 17, 2011, for recipients that are age 19 years and older enrolled in the fee-for-service Medicaid Program. Please note that vaccinations including influenza vaccines for Medicaid recipients through age 18 years are covered by the Vaccines for Children program.


Coverage of Influenza Vaccine for Adults under the FFS Medicaid Program


Previous to this change, influenza vaccine claims could only be billed by pharmacies that used the Medicaid medical claims payment process. DMAS has made changes to the Medicaid  Management  Information System (MMIS) to allow all Medicaid enrolled pharmacies to submit claims for the influenza vaccine using the pharmacy POS claims processing system. Payment methodology for pharmacy products is defined  in VAC 12VAC30-80-40 at Influenza vaccine claims will be  reimbursed using the lowest of the following: Estimated Acquisition Cost (EAC)  which is currently Average Wholesale Price (AWP) minus 13.1%, the provider’s usual and customary charge (U&C), the Federal Upper Limit (FUL) or Virginia’s Maximum Allowable Cost (MAC). In addition the pharmacy will receive the standard dispensing fee of $3.75.


Call Center Information


Useful Telephone Numbers For Medicaid Participating Providers

Telephone Number(s)

Information Provided

Pharmacy Call Center


Pharmacy claims processing questions, including transmission errors, claims reversals, etc., the generic drug program, problems associated with generic drugs priced as brand drugs, obsolete date issues, determination if drug is eligible for Federal


Preferred Drug List (PDL) & Service Authorization Call Center


Questions regarding the PDL program, service authorization requests for non- preferred drugs, service authorization


Medicaid Memo October 27, 2011

Page 2




requests for drugs subject to prospective DUR edits

Maximum Allowable Cost (MAC) & Specialty Maximum Allowable Cost (SMAC) Call Center


Billing disputes and general information regarding multi-source drugs subject to the MAC program, and billing disputes and general information related specialty drugs

subject to the SMAC Program

Provider Helpline


In state long distance: 1-804-552-8627

All other questions concerning general Medicaid policies and procedures


1-800-884-9730 or


Automated Voice Response System for

Verifying Medicaid Eligibility

Medicaid Managed Care Organization (MCO) Information

Amerigroup 1-800-600-4441

Anthem 1800-901-0020

CareNet 1-800-279-1878

Optima 1-800-881-2166

VA Premier 1-800-828-7989

Questions relating to Medicaid and FAMIS Members enrolled in Managed Care Organizations (MCOs). The MCO may utilize different authorization and billing guidelines than those described by DMAS. For more information, contact the MCO




DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, check status, service limits, service authorizations, and  electronic  copies  of  remittance  advices. Providers must register through the Virginia Medicaid Web Portal in order to access this information. The Virginia Medicaid Web Portal can be accessed by going to: If  you  have  any  questions regarding the  Virginia  Medicaid Web  Portal,  please contact the ACS Web Portal Support Helpdesk, toll  free,  at  1-866-352-0496  from  8:00  a.m.  to  5:00  p.m.   Monday   through   Friday,   except   holidays.   The   MediCall audio response system provides similar information and can be accessed by calling 1-800-884-9730 or 1- 800-772-9996. Both options are available at no cost to the provider. Providers may also access service authorization information including status via KePRO’s Provider Portal, effective October 31, 2011 at



DMAS has contracts with the following eligibility verification vendors offering internet real-time, batch and/or  integrated platforms. Eligibility details such as  eligibility status,  third  party liability, and service limits for many  service types and procedures are available. Contact information for each of the vendors is listed below:


Passport Health

SIEMENS Medical Solutions – Health


Communications, Inc.


Foundation Enterprise Systems/HDX


1 (877) 363-3666




1 (888) 661-5657

1 (610) 219-2322




The “HELPLINE” is available to answer questions Monday through Friday from 8:00 a.m. to 5:00 p.m., except on holidays. The “HELPLINE” numbers are:


1-804-786-6273       Richmond area and out-of-state long distance

1-800-552-8627       All other areas (in-state, toll-free long distance)


Please remember that the “HELPLINE” is for provider use only. Please have your Medicaid Provider Identification Number available when you call.