We reimburse pharmacies for prescriptions based on the following methodology:

Prescription drugs and oral or topical over-the-counter medications are nontaxable (RCW 82.08.0281). Orders for over-the-counter non-oral drugs or non-drug items must be written on standard prescription forms.

You can bill for drugs prescribed at the initial visit, even if the State Fund claim has not yet been accepted.

Find out if a prescription is eligible for first fill coverage

A prescription is a first fill when:

• It is prescribed at the initial visit to complete the Report of Accident and
• The claim is a State Fund claim.

A prescription is not a first fill when:

• It is a refill or an additional prescription of a filled drug,
• The claim is a federal or self-insured claim, or
• The prescriber has been excluded from the provider network

You are ready to bill for first fills

1. Obtain a claim number from the patient and bill the prescription through the point-of-sale (POS) system. If the prescription meets criteria for first fill coverage, you will get a rejection code 52 or 67 with the following:
   • Maximum allowed amount: $XX.XX AND
   • A message: "Prescription qualifies for first fill; submit prior authorization number 46484254557 after verifying claim number from report of accident or claim ID card."
2. Verify the claim number from the Report of Accident or claim ID card.
3. Resubmit bill with the above prior authorization number. Make sure to use “08” for the prior authorization type code.

Your bill may reject for a number of reasons

See 3. Your bill may reject for a number of reasons, on the next tab of this page: Submit Pharmacy Bills: Step by Step.

What if you already billed for first fills

1. Bill us and charge the patient according to the maximum allowable amount from the rejection message. The resubmit the bill with the amount paid in the "patient amount submitted" (433-DX) field. We will capture the bill and reimburse the patient if and when the claim is allowed.
2. Submit a paper claim. We will suspend the bill and reimburse you if and when the claim is allowed.
3. Wait until the claim is allowed and then submit the prescription through the POS system.

1. What you need to have before billing

2. You are ready to bill

3. Your bill may reject for a number of reasons

1. What you need to have before billing:

• A provider account
• A State fund claim

Ask the patient for his/her claim number or contact our claim information line at 800-831-5227 for a valid claim number. If you have a claim number, find out whether it is State Fund:

• A connection between your switch vendor and us
  Contact your software or switch vendor to establish a connection. We contract with Switch Vendor eRx to provide switching services for our online point-of-sale (POS) system.
• A decision on your remittance advices
  If you are billing using the POS system, you can choose to receive your remittance advices electronically in the HIPAA compliant ASC X12N 835 format by either:
  • Accessing the Provider Express Billing (PEB) website or
  • Contacting the Electronic Billing Unit at 360-902-6511 or email: ebulni@Lni.wa.gov

2. You are ready to bill

Submit pharmacy bills electronically via the POS system:

• Use the current payer sheet with billing requirements at NCPDP Payer Sheet Version D.0.
• POS hours:
  • Sunday – Friday 6:00 AM – 12:00 AM
  • Saturday 6:00 AM – 10:00 PM

Submit pharmacy bills via paper billing form:

• Use the Statement for Pharmacy Services form for single drugs with NDCs.
• Use the Statement for Compound Prescription form for compounded drug products. You must obtain prior authorization or risk non-payment.
• Use the Statement for Miscellaneous Services form for medical supplies, non-NDC drugs, equipment, orthotics & prosthetics.

3. Your bill may reject for a number of reasons

Drug utilization review or DUR edits

We screen all bills for the following: high dose, therapeutic duplication, level 1 drug-to-drug interactions and refill-too-soon.

When a bill rejects because of DUR criteria, your dispensing pharmacist can review the prescription and use clinical judgment to respond with the appropriate NCPDP DUR conflict, intervention and outcome codes or clarification code if medically appropriate.

Non-preferred and non-covered edits

Preferred Drug List (PDL) provisions

• Rejection code 70 and the message, “TIP Preferred”
  • Non-preferred drug prescribed by endorsing practitioner and substitution is permitted
  • Use therapeutic interchange to substitute for a preferred alternative
• Rejection code 70 and the message, “Alternatives:”
  • Non-preferred drug prescribed by non-endorsing practitioner
  • Contact the practitioner to get a new prescription for a preferred alternative

See the Prescription Drug Program for additional information about PDL provisions.

Non-covered status on drug formulary

• See Drug Lookup tool for covered alternatives OR
• Call the Preferred Drug List hotline at 888-443-6798 or 360-902-4321 Monday – Friday, 8 a.m. to 5 p.m.

Quantity and days' supply edits

Days’ supply limit - Prescriptions are limited to a 30-day supply maximum, except for mail-order and opioids:

• Mail-order for pensioners may be up to a 90-day supply. See Mail-order Services provisions
• Opioid prescription may be up to a 28-day supply, except for dental providers

Certain drugs may also have quantity limits.

Missing, invalid or non-covered prescriber ID

We do not accept provider numbers for large groups, clinics or hospitals.

Make sure you use an individual prescriber number and the appropriate prescriber ID qualifier to bill:

If we do not have the submitted prescriber ID in our records, you will receive rejection code 25.

• Use an alternative prescriber ID number in the above list or
• Call Provider Accounts at 360-902-5140 to update the prescriber information.

If we have not authorized the provider to prescribe on the claim, you will receive rejection code 71.

• If the prescriber is covering for an attending provider, call the Preferred Drug List hotline at 888-443-6798 or 360-902-4321 Monday – Friday, 8 a.m. to 5 p.m.

Pharmacy providers billing through a third party

If you are using a third party pharmacy biller, you must:

• Email L&I Provider Accounts, PACmail@Lni.wa.gov, for a copy of the form. This agreement:
  • Allows the third party pharmacy biller to route bills on your behalf and
  • Shows you agree to follow our rules, regulations and policies
• Ensure that the third party pharmacy biller uses our point-of-sale (POS) system.
• Review and respond to any on-line POS system edits during the dispensing episode. Third party pharmacy billers cannot resolve POS edits.
• Make sure you use your provider ID for the service provider ID and the appropriate service provider ID qualifier. See the Transaction Header Segment of the NCPDP D.0 specifications below: