North Carolina Health Choice (NCHC)
Frequently Asked Questions for Pharmacists

General Information | Pharmacy Services | Reimbursement Issues | Other

GENERAL INFORMATION

1. What is NC Health Choice for Children?

It is a fee-for-service health insurance program that provides free or low-cost health coverage to uninsured children under the age of nineteen whose families cannot afford private health insurance and who do not qualify for Health Check (Medicaid). The program was established in October 1998 by the federal government and the state of North Carolina. It is modeled after the State Teachers' and Employees' Comprehensive Major Medical Plan and is administered by BlueCross and BlueShield of North Carolina (BCBSNC) with the exception of pharmacy benefits, which are managed by AdvancePCS, and mental health, which is managed by ValueOptions, Inc. Children are enrolled into NC Health Choice on a first-come, first-serve basis.

2. What services does NC Health Choice for Children cover?

NC Health Choice for Children is a comprehensive health insurance program covering a range of services for children. These include acute care, preventative care services, hospitalization, prescription drugs, durable medical equipment, medical supplies, and special hearing and vision benefits. Dental benefits include prophylactic, evaluative and therapeutic services. Almost all services for children with special needs are covered. No special application for these services is necessary. Details on NC Health Choice covered services can be found in the member handbook which is available online.

3. How will I know that an individual is a member of the NC Health Choice for Children plan?

Children will have a card identifying them as members of the NC Health Choice for Children plan. Members have one year of continuous eligibility; the expiration date is on the card. Very rarely, it is possible for benefits to end prior to the date stamped on the card. This could occur if the child reached the age of 19 prior to the end date, became eligible for Medicaid or was found to have other insurance coverage. If the pharmacist wishes to eliminate this small risk, coverage can be confirmed by calling the AdvancePCS Customer Service line at 888-693-7750 or the Customer Service line at BCBSNC 800-422-4658.

NC Health Choice is not renewed automatically. Review the certification period each time you see the patient and remind them to start the re-enrollment process 2 months prior to the end of their certification period. If the patient is found to be ineligible at re-determination, you will not be reimbursed by NC Health Choice for prescriptions that are filled after the original termination date.

4. What does a pharmacist need to do in order to have claims processed by AdvancePCS?

The pharmacy should call AdvancePCS at 800-364-6331. Someone will walk the pharmacist through the process to become a contracted pharmacy.

PHARMACY SERVICES

5. Does NC Health Choice for children cover disease management services by pharmacists?

Currently, a pilot project for asthma management services is being developed and will be offered in the following 10 counties: Alamance, Buncombe, Guilford, Durham, Haywood, Nash, Wake, Wilson, Onslow, and Rockingham. To get reimbursed, pharmacists will need to complete an asthma certification program and be a member of the Piedmont Pharmaceutical Care Network. With questions, call the NC Association of Pharmacists (NCAP) at 800-852-7343.

REIMBURSEMENT ISSUES

6. How much is a pharmacist reimbursed for prescriptions and durable medical equipment?

Currently, reimbursement allowances for prescription drugs are 90% of the Average Wholesale Price (AWP) plus a $6 dispensing fee.

Durable medical equipment (DME) and covered medical supplies (e.g., syringes, diabetic testing supplies, colostomy bags, catheters) are reimbursed at 100% of the usual customary rate (UCR) by the NC Health Choice members' medical carrier (BCBSNC). No copay should be received from the Health Choice member.

A pharmacist can either file for reimbursement for DME and medical supplies through AdvancePCS, or send a HCFA 1500 form to BCBSNC. When a claim is filed through AdvancePCS, AdvancePCS will return a message to the pharmacist that reads, "collect no copay, amount due billed to BCBSNC." AdvancePCS will notify BCBSNC of the bill and the pharmacy will be reimbursed by BCBSNC.

If the pharmacist chooses to file with BCBSNC directly, he or she should send a completed HCFA 1500 form to NC Health Choice at P.O. Box 30025, Durham, NC 27701-3111.

All rentals need prior approval. Prior approval is also required for all purchases and repairs over $500. The prior approval process should be initiated by the patient or physician. For information about prior approvals, call NC Health Choice Review at 1-800-422-1582 (fax: 919-765-4890) or consult the member handbook which is available online.

Reimbursement rates are legislatively approved and subject to change.

7. How will I know what copayment to collect?

Some families are subject to copayments of $6 for prescription drugs and others are not. Check the member's insurance card. If the member's card shows $0.00 beside "drug copay," no copayment is required.

Copayments are subject to online adjudication.

There are no copays for durable medical equipment or covered medical supplies (e.g., syringes, diabetic testing supplies, colostomy bags, catheters).

When the total copay amount for a covered family reaches five percent of the family's income, no further copayments are to be collected. When this occurs, BCBSNC will send the member a letter stating that the copayment maximum has been met for the remainder of the member's 12- month period. The letter will specify the date when he or she must resume making copayments. It is the responsibility of the member to share this information with you. You may also contact the BCBSNC State Customer Service department at 1-800-422-4658 to verify this information. You will continue to receive your full, allotted reimbursement.

8. What does the pharmacist need to know about entering prescription card information into the computer?

Prescription claims capturing is provided by National Data Corporation. Each pharmacy's procedure for entering prescription card information will vary depending upon the type of software that they use. For information specific to your pharmacy, contact your pharmacy's software vendor.

9. How often can a prescription be refilled and are there limitations on the quantity dispensed?

There is no limit on the days supply for NC Health Choice members.

10. Is there a way to prevent duplication of medication?

The AdvancePCS claim adjudication system will not allow duplication of medications to occur.

11. What happens if a patient has applied for NC Health Choice for Children, but has not yet received coverage?

If the NC Health Choice member has paid the pharmacy for their medication and then received retroactive eligibility that covers this period, the NC Health Choice member can submit a paper claim to AdvancePCS for reimbursement. The reimbursement would be payable to the member. A claim form can be requested by calling the Customer Service line, 888-693-7750 or can be downloaded from the Web site http://statenc.advparadigm.com/. You may wish to assist the NC Health Choice member in completing the form.

The completed claim form should be sent to the attention of Lee Glenn at AdvancePCS, 1330 East Campbell Road, Richardson, TX 75081.

12. Can I charge the NC Health Choice for Children member for the difference between my charges and the BCBSNC reimbursement?

No. You cannot bill a NC Health Choice for Children member any amount other than the copayment.

13. What should I do if I do not agree with a decision to deny a claim, or if I disagree with the reimbursement provided?

The pharmacist will be contacted either by the AdvancePCS Customer Service Representative or the Account Management Team for further discussion.

OTHER

14. Who do I contact if I have questions or concerns?

To verify member eligibility, call the AdvancePCS Customer Service line at 888-693-7750 or Customer Services at BCBSNC, 800-422-4658.

With questions about prescription drug benefits call the AdvancePCS Customer Service line, 888-693-7750.

For questions about medical supplies, call Customer Service at BCBSNC at 1-800-422-4658.

For prior approval for durable medical equipment, call Medical Review at 1-800-422-1582
(fax: 919-765-4890).

With technical questions, e.g., transmitting claims, call the AdvancePCS Pharmacy Help Desk at 800-364-6331.

If you have feedback that you would like to share with a pharmacy representative from the NC Health Choice for Children Provider Task Force, contact Rebecca Sasser, Pharm.D.,at 919-832-4641.

Information contained in this document is the best information available as of December 2001 and is subject to change. Sources include:

1. "The North Carolina Pediatrician," a publication of the North Carolina Pediatric Society. Spring, 1999.
2. Memo from the State of North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan and NC Health Choice, BlueCross and BlueShield of North Carolina, September 1998.
3. Conversations with Richard Edwards, Client Manager, AdvancePCS.
4. Conversations with Connie Williams, Provider Relations Specialist, BlueCross BlueShield of North Carolina and member of the NC Health Choice for Children Provider Task Force.
5. Input from other members of the NC Health Choice for Children Provider Task Force, the North Carolina Association of Pharmacists, and the pharmacy community of Buncombe County, NC.

Preparation of this guide was assisted by a grant from The Robert Wood Johnson Foundation, Princeton, N.J.

For more information about NC Health Choice, please contact your local Department of Social Services. The number can be found in your phone book under "County Government." 12/2001

Updated June 16 , 2005