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How to Submit Prescriptions for Cancer Drugs Dispensed in Physician Offices
by Marie Kaye
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Overview
Each state has its own rules on physician practice, including whether a physician office can dispense prescription drugs to patients. In states permitting physician dispensing of cancer drugs, physician offices often find that offering this point-of-care option is convenient for patients and potentially profitable for the practice.
Prescription drugs for cancer can be very expensive, so patients should submit prescription drug claims to insurers quickly and correctly.
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Step 1
Ask your physician's office if they will fill out and submit prescription reimbursement claims and charge only the co-payment before trying to complete and submit claims on your own. For oral cancer medications dispensed in the office, oncology practices are often willing to submit claims as an added patient convenience.
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Step 2
Obtain from your insurer (and make sure you understand) all information on coverage requirements for the particular cancer drug(s) dispensed in the physician office before submitting yourself.
Due to the rising costs of cancer treatments, most insurers maintain a variety of cost and utilization control tools to make sure that coverage and payment for expensive cancer drugs is cost-effective and appropriate. Prior authorization is a common restriction that requires the physician to give information to the insurer on why a particular therapy is necessary before he prescribes and dispenses it. Failing to comply with these requirements can jeopardize reimbursement and create high out-of-pocket costs for the patient.
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Step 3
Complete the patient information portion of the claim form accurately. This information includes the primary policyholder's name and address, the name of the patient, and the insurance member and group number.
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Step 4
Ask your physician office to complete the "pharmacist" portions of the form. In the space for "diagnosis," the office should supply the symptom or condition for which the medicine is needed. This means that if a pain medication is dispensed, the "diagnosis" would be pain or cancer pain. For chemotherapy and other disease-modifying drugs, the physician should include the diagnosis code describing the specific type of cancer.
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Step 5
Attach receipt(s) for the dispensed drug(s). Ensure that the drug name, dosage and quantity dispensed match the receipt and the information supplied on the claim form.
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Step 6
Mail or fax the claim form and receipts according to insurer instructions. Most plans require that claims be submitted within specific time limits.
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Step 7
Contact the insurer customer service department if reimbursement is not received within three weeks.
If the insurer denies a claim for cancer drugs dispensed in a physician office, let your doctor know and request that he contact the insurer to appeal the denial.
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- Prescription drug claim form
Receipt for drug purchase
Policy number from health insurer
- Prescription drug claim form
- Receipt for drug purchase
- Policy number from health insurer
