tenncare pharmacy network re contracting
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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.

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Presentation Transcript
why re contract the pharmacy network
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?
who is required to re contract
Owning entity must re-contract

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 stores

Who is required to re-contract?
key changes in the new pharmacy network agreement
Clarified definition of ambulatory pharmacy

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 required

Key Changes in the New Pharmacy Network Agreement
instructions for re contracting
Must submit 3 documents:

Signed pharmacy network agreement

Pharmacy network application

Disclosure form

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 network

Instructions for Re-Contracting
pharmacy agreement instructions
Lays out all of the terms and conditions

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 website

Pharmacy Agreement Instructions
pharmacy application instructions
Pages 27-28 of the network document

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
disclosure form instructions
Disclosure form instructions begin on page 30 of the network document

Form consists of 6 sections, labeled Items I – VI.

Item I: Identifying information

Provider Type

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
disclosure form instructions1
Item II – Ownership and Control Information

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
disclosure form instructions2
Item IV – Criminal Offenses

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 affiliations

Disclosure Form Instructions
disclosure form instructions3
Item VI – Board of Directors / Board of Governors

Must disclose identities and percentage of controlling interest

Signature / Date

Disclosure Form Instructions
take away points
3 documents required:

Signed Agreement


Disclosure form

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 status

Take Away Points