ForwardHealth implemented the MTM (Medication Therapy Management) benefit in conjunction with the WPQC (Wisconsin Pharmacy Quality Collaborative). The MTM benefit consists of CMR/A (Comprehensive Medication Review and Assessment) services, which are private consultations between a pharmacist and a member to review the member's drug regimen.
Step 1: Enroll in Wisconsin Medicaid
To be reimbursed for services provided to members enrolled in Wisconsin Medicaid, BadgerCare Plus, or SeniorCare, providers are required to be enrolled in Wisconsin Medicaid as described in Wis. Admin. Code ch. DHS 105.
Note: many pharmacies may already be enrolled in Wisconsin Medicaid prior to providing MTM services as it is a requirement to be reimbursed for dispensing services
Step 2: WPQC Certification
WPQC certification is required to perform and receive reimbursement for CMR/A services.
To perform and be reimbursed for CMR/As, the pharmacists and the pharmacy at which a pharmacist is performing the CMR/A are required to be certified by an approved MTM program. Currently, the only approved MTM certification program is offered by the WPQC. The PSW (Pharmacy Society of Wisconsin) manages the WPQC training and certification process, and has established rates for WPQC certification.
Step 3: Understand MTM Reimbursement
Pharmacy providers can be reimbursed for delivering two levels of MTM service codes to ForwardHealth members. These are categorized using CPT codes that describe the level of care provided and include the following:
99605 - MTM service provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, new patient ($85)
99606 - MTM service provided by a pharmacist, individual, face-to-face with patient with assessment and intervention if provided; initial 15 minutes, established patient ($40)
Pharmacist billing through DocStation can earn up to $205 per member per rolling year in the ForwardHealth MTM program!
It is important to note that an initial visit (CPT 99605) can only be performed once per member per rolling year, while the follow-up visit (CPT 99606) can be performed up to three times per member per rolling year. If more visits are warranted, refer to the ForwardHealth Pharmacy Provider manual for further instruction.
Step 4: Enable Claims in DocStation!
Activate the DocStation Essentials or Premium subscription to start billing for your clinical services, and so much more, today!
Note: DocStation "Getting Started" assistance does not replace the requirements of the Wisconsin Department of Human Services. Please refer to the ForwardHealth Pharmacy Provider Manual for complete guidance.