Billing L&I for Pharmacy Services
For pharmacy providers who bill L&I directly
Point-of-sale system (POS) for reimbursement
Use the NCPDP Payer sheet ver. 5.1 (142 KB PDF) for billing format. Effective 01/01/2012 use the NCPDP Payer Sheet ver. D.0 for billing format.
POS hours:
- 6 a.m. to midnight Monday through Saturday.
- 6 a.m. to 10 p.m. on Sunday.
To receive remittance advice in the HIPAA compliant EDI 835 transaction, see
Pharmacy 835 Companion Guide (606 KB PDF / 3 min).
Paper forms for reimbursement
For State Fund claims
- Statement for Pharmacy Services form (F245-100-000).
OR - Statement for Compound Prescription form (F245-010-000).
Dispensing compound prescriptions requires prior authorization.
For Crime Victim claims
- Statement for Pharmacy Services - Crime Victims form (F800-058-000).
OR - Statement for Compound Prescription - Crime Victims form (F800-067-000).
Dispensing compound prescriptions requires prior authorization.
Helpful billing information
To prevent a rejection to your prescription (71 - Prescriber not covered) use the prescriber's:
- State license number.
- Individual L&I provider number. *
- National Provider ID (NPI).
- DEA number.
* L&I provider numbers for large groups, clinics or hospitals are no longer accepted for prescription billing.
For pharmacy providers billing through a third party pharmacy biller
In order to use a third party pharmacy biller, you must:
- Have a signed Supplemental Agreement Third Party Pharmacy Provider form (F249-021-000). This agreement:
- Allows the third party pharmacy biller to route bills on the pharmacy's behalf and
- Shows you agree to follow L&I rules, regulations and policies.
- Ensure that the third party pharmacy biller uses the POS system.
- Review and resolve all on-line POS system edits during the dispensing episode.
- Only a licensed pharmacist can resolve POS system edits.
- Third party pharmacy billers cannot resolve POS edits.
The following table shows the required entries in the Transaction Header Segment of the NCPDP 5.1 specifications when billing through a third party pharmacy biller.
| Transaction Header Segment - Required | |||
|---|---|---|---|
| Field name | Data element number | Required | Valid values/comments |
| Service provider ID qualifier | 202-B2 | Yes | 13 [State Issued] Other valid values are accepted but not for third party billing. |
| Service provider ID | 202-B1 | Yes | Enter 7-digit L&I dispensing pharmacy provider ID associated with the third party pharmacy biller. Other valid values are accepted but not for third party pharmacy billing. |
Pharmacy providers who submit bills on their own behalf and also use a third party pharmacy biller need to be sure to use the correct service provider ID. Payments will be made to the account associated with the submitted service provider ID.
First Fills
L&I will pay pharmacies or reimburse workers for prescription drugs prescribed during the initial visit only.
L&I will not pay:
- For refills of the initial prescription or any additional prescriptions for the original injury before the claim is accepted. OR
- If it is a federal or self-insured claim.
Payment for initial prescription drugs shall be based on L&I's fee schedule. Your bill must be received by L&I within one year of the date of service.
Using the point-of-sale (POS) system
To obtain a valid State Fund claim number for billing, you must see a copy of the report of accident (ROA) or the claim ID card. See an example of the ROA with attached ID card (217 KB PDF / 1 min).
When the prescription meets criteria for guaranteed payment, the POS system will send rejection code 52 or 67 with the following information:
- 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."
Remember to submit a valid prior authorization qualifier (08) along with the authorization number.
How to identify a State Fund claim
State Fund claim numbers are alpha-numeric, consisting of 7 characters. They begin with B, C, F, G, H, J, K, L, M, N, P, X, or Y followed by 6 digits or double alpha (e.g. AA, AB, AG) followed by 5 digits. See an example on this ROA with attached ID card sample (217 KB PDF / 1 min).
The following table shows the required entries in the Transaction Header Segment of the NCPDP 5.1 specifications.
See RCW 51.36.010 (www.leg.wa.gov) for more information.
| Transaction Header Segment | |||
|---|---|---|---|
| Field name | Data element number | Required status | Valid values/comments |
| Prior authorization type code | 461-EU | Optional | 08 - Payer defined exemption for use with reject code 52 or 67. |
| Prior authorization number submitted | 462-EV | Optional | Enter prior auth 46484254557 after verify the claim number from the ROA or claim ID card for initial prescription. |
| Dispense as written/product selection code | 408-D8 | Optional | Valid values: 0=No product selection indicated (substitution permitted) 1=Substitution not allowed by prescriber (DAW) 6=Override for emergency supply of drug requiring prior authorization. |
Refill(s) and/or additional prescription dispensed before claim acceptance
- You may charge the injured worker for the prescription and submit the bill with the amount paid in the patient paid amount or co-pay field. L&I will capture the bill and reimburse the injured worker if and when the claim is allowed.
- You may submit a paper bill. L&I will suspend the bill and reimburse you when the claim is allowed.
- You may wait until the claim is allowed and then submit it through the POS system.
How to obtain authorization
What information is needed before calling for authorization:
- Injured worker’s claim number
- Pharmacy’s L&I provider account number or prescribers’ L&I provider account number or license number
- Drug name and NDC
- Condition the drug will be used to treat
Who to call:
Call PDL hotline: 1−888−443−6798 or 360−902−4321 Monday through Friday, 8 a.m. to 5 p.m. PT.
PDL or First Fills Non-preferred Drug Requests:
- If the pharmacy receives a prescription after normal business hours or during weekends or Washington State holidays, you may:
- Dispense the drug under the worker's primary insurance or straight cash transaction and request authorization the next business day.
- Dispense an emergency supply of the drug (enter a value of 6 in the DAW field) and request authorization the next business day. L&I considers an emergency supply for most drugs, up to 10 days.
- When you call L&I, you will need to give a diagnosis, or information on the condition being treated.
Pharmacy Fee Schedule
Payment for drugs, including all oral non-legend drugs, will be based on the pricing methodology described below.
| Drug type | Payment method |
|---|---|
| Generic | AWP less 50% + $4.50 professional fee. |
| Single or multisource brand | AWP less 10% + $4.50 professional fee. |
| Brand with generic equivalent (dispense as written only). | AWP less 10% + $4.00 professional fee. |
| Compound prescriptions. | Allowed cost of ingredients + $4.50 professional fee + $4.00 compounding time fee (per 15 minutes). |
Refer to WAC 296-20-01002 for definition of average wholesale price (AWP).
View L&I's Outpatient Formulary.
Orders for over-the-counter non-oral drugs or non-drug items must be written on standard prescription forms. These items are to be priced on a 40% margin. Prescription drugs and oral or topical over-the-counter medications are nontaxable (RCW 82.08.0281 (www.leg.wa.gov)).
Screenings
All pharmacy bills will be screened for:
- Drug utilization review (DUR) criteria, such as high dose, therapeutic duplication and level 1 drug-to-drug interactions,
- Preferred drug list (PDL) provisions,
- 30-day supply limit, and
- Formulary status including the PDL.
Rejections associated with these screenings must be addressed by the dispensing pharmacist before the bills will be payable.
How to override DUR edits
When a DUR condition exists on a bill, the POS system will send rejection code 88. After conducting a review, the dispensing pharmacist may use the appropriate NCPDP DUR conflict, intervention and outcome codes to override the denial if it is medically appropriate. See the NCPDP Payer sheet (97 KB PDF).
How to override PDL provisions
The dispensing pharmacist must interchange a preferred drug for a non-preferred drug when prescribed by an endorsing practitioner unless "dispense as written" or DAW is noted on the prescription.
Non-preferred drug prescribed by endorsing practitioner
When you bill for a non-preferred drug written by an endorsing practitioner and substitution is permitted, the POS system will send:
- Rejection code 70,
- A secondary message, "TIP Preferred:"
- Notice that a therapeutic interchange is required.
If the endorsing practitioner indicates DAW on the initial prescription, you must bill L&I using a value of 1 in the DAW field.
Non-preferred drug prescribed by non-endorsing practitioner
When you bill for a non-preferred drug written by a non-endorsing practitioner, the POS system will send:
- Rejection code 70,
- A secondary message, "Alternatives:"
- Notice that a new prescription for a preferred drug is required.
If you receive an initial prescription after normal business hours or during weekends or Washington State holidays, you may:
- Dispense the non-preferred drug and
- Bill L&I using a value of 6 in the DAW field.
Your request must be made to L&I before further coverage is provided.
