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Medication Therapy Management Case Management Software Approval Process

Medication Therapy Management Case Management Software

The Department of Health Services in conjunction with the Wisconsin Pharmacy Quality Collaborative — a group of pharmacy providers, health care purchasers, and medical professionals working together to reduce long term health care costs — implemented a Medication Therapy Management (MTM) benefit on September 1, 2012.

ForwardHealth's MTM benefit consists of Comprehensive Medication Review and Assessment services. Comprehensive Medication Review and Assessment services are in-depth analyses by a pharmacist of members' health statuses, including the formulation of treatment plans, documentation and communication with primary care providers, referrals to other health care providers, and coordination and integration of medication management services with the broader health care system. For more information about ForwardHealth's MTM benefit, refer to the Pharmacy service area of the Online Handbook.

Currently pharmacies can submit claims for MTM services provided to BadgerCare Plus, SeniorCare, and Wisconsin Medicaid members using the 837 Health Care Claim: Professional transaction; the ForwardHealth Portal; ForwardHealth's free claim submission software, Provider Electronic Solutions; or the 1500 Health Insurance Claim Form.

ForwardHealth will approve MTM case management software that meets specific requirements to facilitate MTM services. Among the initial approval requirements, MTM case management software must have decision-support tools that will, at a minimum, identify BadgerCare Plus, SeniorCare, and Wisconsin Medicaid members who have diabetes as well as members who are taking four or more drugs to treat or prevent two or more conditions in which one of the conditions is asthma, Chronic Obstructive Pulmonary Disease (COPD), chronic kidney disease, depression, dyslipidemia, heart failure, or hypertension. For more information about software requirements, refer to the Medication Therapy Management Case Management Software Requirements checklist, F-00855.

Approved MTM case management software will apply algorithms to member claim information accessed from a Secure File Transfer Protocol server to identify members eligible for a CMR/A service. Additionally, approved software must capture and store certain information about the service provided and send the information to ForwardHealth. ForwardHealth will use this information to evaluate the MTM benefit. Software may, but is not required to, enforce ForwardHealth's other MTM policies (e.g., the number of allowable MTM services) as described in the Pharmacy service area of the Online Handbook.

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