Common use of Processed Clause in Contracts

Processed. The Division will provide the Contractor with additional information and requirements regarding its obligation to cooperate with the PBA throughout the life of this Contract. Any PAD that is billed on an outpatient medical claim, instead of pharmacy claim, will still be the responsibility of the Contractor. The Contractor will not implement any strategy or policy that will intend to shift medication coverage of these drugs to the pharmacy benefit. The Division will provide forty-five (45) calendar days advance written notice to the Contractor prior to removing pharmacy coverage for any physician administered drugs that may be also covered on the pharmacy benefit, to allow the Contractor time to provide impacted members advance notice to ensure continuity of care. Contractor shall maintain its PBM to perform claims processing/encounter submissions for pharmacy and PADs claims submitted with dates of service prior to the effective date of live operations of the Division PBA. Contractor is required to maintain its PBM for a period of time to allow all timely filing and timely processing periods to expire with regard to such claims. The Contractor shall maintain the same unique BIN/PCN number in effect prior to July 1, 2024 for the processing of pharmacy claims for the purpose of separating the Contractor’s third-party private pharmacy provider claims from CHIP claims. Contractor must also maintain the same unique network reimbursement ID for CHIP claims. The Contractor must have a drug utilization review (DUR) program to conduct prospective and retrospective utilization review of prescriptions. The DUR program must comply with 42 C.F.R. § 438. The Contractor must submit an annual report to the Division that provides a detailed description of its DUR program activities both prospective and retrospective reviews. The Contractor shall process claims for PADs to Members enrolled in the CHIP Program as defined in the Mississippi Administrative Code, Title 23, Part 203. These claims shall be submitted on CMS 1500 and UB-40 claim types. The Contractor must use the most current version of the MS DOM Universal PDL, which is subject to periodic changes. The Contractor must use the Medicaid PDL developed by the Division or its Agent and may not develop and use its own PDL. The Contractor will be provided opportunities to offer feedback on the PDL to the Division. A pharmacy representative from Contractor shall attend the P&T committee meetings as a guest and will be offered the opportunity to contribute in an evaluative and educational capacity in post P&T committee meetings. The Executive Director of the Division has final authority on drugs with preferred and non-preferred status on the PDL. The Contractor shall follow the same PA criteria of that of FFS for drugs requiring PA, regardless of PDL status. The Contractor shall not promote any preferred drugs over other preferred drugs. The Contractor must refer to the Pharmacy Services page on the Division’s website for a current listing of prescription drugs on the PDL to ensure continuity of care for Members. Pursuant to 42 C.F.R. § 438.10(i), Contractor, upon request by a Member or the Division PBA on behalf of a Member, must provide access to Members in paper and electronic form the following Preferred Drug List information: which medications are covered (generic and name brand), and the information must be made available on the MCOs website. The Contractor must make available a link to the Universal PDL on their website. The Contractor may require Prior Authorization in accordance with Section 5.I of this Contract for drugs outside the PDL. The Contractor shall ensure that prescribed drugs, and PADs are dispensed and/or administered in accordance with medically accepted indications and dosing limits supported by one (1) or more of the official compendia as designated by the Centers for Medicare and Medicaid Services (CMS). No payment may be made for services, procedures, devices, supplies or drugs which are still in clinical trials and/or investigative or experimental, cosmetic, or unproven in nature. The Contractor is not authorized to negotiate rebates for preferred products. The Contractor shall provide coverage of covered outpatient drugs billed on a medical claim and as defined in section 1927(k)(2) of the Act, that meets the standards for such coverage imposed by section 1927 of the Act. The Contractor shall continue to report drug utilization data that is necessary for the Division to bill manufacturers for rebates for PADs in accordance with section 1927(b)(1)(A) of the Act no later than thirty (30) calendar days after the end of each quarterly rebate period of the Division. Such utilization information must include, at a minimum, information on the total number of units of each dosage form, strength, the billing provider’s NPI number and package size by National Drug Code of each covered outpatient drug dispensed or covered by the Contractor. Contractor must enforce the Division’s billing requirements for 340B claim submissions billed by registered 340B covered entities. The Contractor must conduct a prior authorization program for PADs that complies with the requirements of section 1927(d)(5) of the Act. Please refer to Mississippi Administrative Code, Title 23, Part 203. The Contractor shall report information specified by the Division to enable the collection of rebates by the Division, as described in Section 10, Reporting Requirements, of this Contract. The Division, including the Division’s Office of Program Integrity, must be informed of all Pharmacy-related audits for claims processed by the Contractor, whether desk audits or onsite. The Contractor must complete all audits of a Provider clean claim processed by the Contractor within a timeframe consistent with state law. For claims processed by the Contractor, if the audit indicates that the Contractor is due a refund from the Provider, the Contractor must send the Provider written notice of the basis and specific reasons for the request. The Contractor must give the Provider an opportunity to appeal. All other language not modified as stated herein for Section 5.F shall remain unchanged and in full force and effect.