TennCare Pharmacy Network Re-contracting. The federal government requires all Medicaid providers to disclose information on ownership and control information, as well as business transactions.
The federal government requires all Medicaid providers to disclose information on ownership and control information, as well as business transactions.
A CMS audit found the current TennCare pharmacy network agreement did not adequately meet disclosure requirements.
The new pharmacy network agreement requires submission of a mandatory disclosure form.Why re-contract the pharmacy network?
Owning entity must re-contract disclose information on ownership and control information, as well as business transactions.
For chains, corporate office can re-contract for all their chain stores
For independents, the pharmacy owner must re-contract
For franchise stores, the franchise owner must re-contract
The corporate office of franchise brand cannot re-contract on behalf of individual franchise storesWho is required to re-contract?
Clarified definition of ambulatory pharmacy disclose information on ownership and control information, as well as business transactions.
Clarified that auto-refills are not allowed
Clarified “as directed” or “prn” are not considered acceptable directions on Rx claims
Inserted a link to the specialty rate table
Clarified requirements for reporting fraud; included new fraud reporting form as attachment
Disclosure form requiredKey Changes in the New Pharmacy Network Agreement
Must submit 3 documents: disclose information on ownership and control information, as well as business transactions.
Signed pharmacy network agreement
Pharmacy network application
Documents can be found under the Pharmacy Network Information link at: https://tnm.providerportal.sxc.com
Pharmacies may submit either an Ambulatory/LTC application/agreement or a Specialty Pharmacy application/agreement
Conference call will focus on the Ambulatory/LTC networkInstructions for Re-Contracting
Lays out all of the terms and conditions disclose information on ownership and control information, as well as business transactions.
Must fill out pages 1 and 25 of the network document (signature mandatory)
Attachment A contains the pharmacy fee schedule
No changes in reimbursement from last contracting period
Attachment B contains specialty rates
As in the last contracting period, this list is subject to change
Updated specialty rate table posted on SXC’s websitePharmacy Agreement Instructions
Pages 27-28 of the network document disclose information on ownership and control information, as well as business transactions.
2 page form – both pages required
Mostly collects basic information such as NPI, pharmacy name, address, phone, owner
Also includes some questions about any license suspensions, probationary status, disciplinary actions, etc.Pharmacy Application Instructions
Form consists of 6 sections, labeled Items I – VI.
Item I: Identifying information
Choose individual pharmacy provider if independent pharmacy with only one location.
Choose disclosing entity if chain pharmacy or independent pharmacy with more than one location.Disclosure Form Instructions
Must disclose any individual/entity having ≥5% ownership or controlling interest in the pharmacy.
If individuals with ≥5% ownership are related, must identify how related.
Must disclose any subcontractor or disclosing entity in which the pharmacy has ≥5% ownership or controlling interest.
Item III – Business Transaction Information
Must disclose ownership of any subcontractor with whom the pharmacy has had business transactions totaling >$25,000 in the last year.
Must disclose any significant business transactions between the pharmacy and any wholly owned subsidiary or subcontractor in the last 5 years.Disclosure Form Instructions
Item IV – Criminal Offenses document
Must disclose any criminal offenses related to involvement in a Medicare, Medicaid, or Title XX services program
Applies to any owners or employees of the practice
Item V – Status Changes
Only fill out if chain or independent pharmacy with more than one location
Must disclose any changes in ownership within the past year
Must disclose any past or present chain affiliationsDisclosure Form Instructions
Must disclose identities and percentage of controlling interest
Signature / DateDisclosure Form Instructions
3 documents required: document
Documents posted on SXC’s website: https://tnm.providerportal.sxc.com
Documents must be returned before 2/1/11
Submission by 1/1/11 required to ensure adequate time for processing
Documents submitted after 1/1/11 will be processed as quickly as possible in the order received
Direct any questions to:
SXC Provider Relations: [email protected], 480-362-5227, or
SXC Provider Educators:
Western TN: Jud Jones, 630-352-8897
Middle TN: Robert Dinwiddie, 630-352-8895
Eastern TN: Kim Brunger, 630-352-8896
SXC will send confirmation notices to pharmacies informing them of network statusTake Away Points