Claims for intervention-based services must be submitted fee-for-service on a professional claim by the pharmacy. In order to be reimbursed for intervention-based services, the pharmacy must submit a professional claim using a valid CPT code and modifier via one of the following claims submission methods:
ForwardHealth reduces reimbursement on most claims submitted to ForwardHealth on paper. Most paper claims are subject to up to a $1.10 reimbursement reduction per claim.
Note: Cost-effectiveness, dose/dosage form/duration change, medication addition, medication deletion, and three-month supply intervention-based services are the only intervention-based services covered for members residing in a nursing facility.
Reimbursement limits for MTM services are applied per member (not per pharmacy). Pharmacy providers are encouraged to submit claims for intervention-based services as soon as possible after provision of the service.
When submitting claims for intervention-based services for a new patient, pharmacies should indicate CPT code 99605 with the appropriate modifier, with a quantity of "1" for the first 15 minutes. If an intervention-based service lasts longer than 15 minutes, pharmacies should indicate CPT code 99607, with the appropriate modifier on a separate detail, for each additional 15 minutes.
When submitting claims for intervention-based services for an established patient, pharmacies should indicate CPT code 99606 with the appropriate modifier, with a quantity of "1" for the first 15 minutes. If an intervention-based service lasts longer than 15 minutes, pharmacies should indicate 99607, with the appropriate modifier, for each additional 15 minutes.
Pharmacies should note the following when submitting claims for each additional 15 minutes of an intervention-based service using CPT code 99607:
Claim details for procedure code 99607 that are billed with a zero dollar amount are placed in a "pay" status with an amount paid of $0.
Although procedure code 99607 will be reimbursed at zero dollars, pharmacies must submit details with the correct quantities to comply with correct coding practices.
When submitting claims for MTM services, pharmacies should note that a new patient is one who has not received any MTM services from the pharmacy within the past three years. An established patient is one who has received MTM services from the pharmacy within the past three years. The CPT procedure code that a provider uses to bill the first 15 minutes of an MTM service indicates whether the member is a new (procedure code 99605) or an established (procedure code 99606) patient.
Providers billing multiple MTM services for any one member on the same DOS are reminded to use the appropriate CPT procedure code for that DOS. Claims will be denied if the member is indicated as both a new patient and an established patient on the same DOS.
Note: The DOS is defined as the date the medication was dispensed, if applicable (e.g., for a cost-effectiveness intervention), or the date the member received the MTM service (e.g., for a medication deletion intervention).
When a pharmacy performs the same type of MTM service more than once for the same member on the same day, the services must be listed as separate claim details. For example, if a pharmacist converts two of a member's prescriptions to a three-month supply on the same day, the pharmacist would list each three-month supply conversion as a separate claim detail, as shown on the sample 1500 Health Insurance Claim Form.
If a medication addition intervention and a medication deletion intervention occur at the same time and one medication is replacing another, providers should submit a claim only for the medication addition.
If a medication addition intervention and a medication deletion intervention occur at the same time but are unrelated, providers may bill separately for the interventions, either on separate detail lines or on separate claims.
