Pharmacy claims

Pharmacy claims cover the medicine subsidy and dispensing costs associated with supplying prescribed pharmaceutical items to patients.

The Services are defined in the Agreement. Pharmacy payments are determined by the Agreement and variations to the Agreement.

Different transaction types generally have different processing requirements. For example:

  • supply orders and Controlled Drug items have no patient contribution (known as abatement)
  • the patient contribution for Special Food items are calculated differently when different flavours are claimed on the same prescription form
  • Owe and Wastage items have no abatement or dispensing fees.

PHARMAC supplies a monthly Pharmaceutical Schedule, containing pharmaceutical pricing and dispensing regulations, which are used to determine the subsidies.

Dispensing costs are defined in the Agreement, and are funded by the district health boards.

On this page:


Questions and answers

Who do I contact to order more pharmacy stationery?

Call 0800 855 066 to obtain copies or email [email protected].

  • High Use Health Card applications
  • Bulk Supply Order forms
  • Practitioner’s Supply Order forms
  • Batch Record Sheet (these are also available from within the Pharmacy Software; please contact your software vendor if you have any questions)

Please note that we will request your claimant details.

How do I obtain a Pharmacy Agreement?

If you have any questions or wish to arrange an agreement then please contact your district health board in the first instance.

My pharmacy claims electronically. What do we do with the hard copy prescriptions?

Pharmacies must retain prescription batches for 5 months. After the 5-month period, prescription batches must be submitted to Sector Operations once or twice each month.

Send all completed claims to:

Ministry of Health Archives Warehouse
137 London Street
Whanganui 4500


Remittance Advice Codes

The following table lists codes  that are the standard approach to referencing/coding payments on the pharmacy's remittance advice.

Remittance Advice Codes
Remittance Code Description of Remittance Advice Codes
Casemix ADV (month/year)     Advance Case mix for that month
Casemix REV (month/year)     Reversal of Case  mix that month
Casemix ACT (month/year) Actual Case mix for that month
APASM (month/year) APASR (month/year) Both APAS payments for that month
LTCYYYYMM LTC for that month
LTCYYYYMM-2-OOC LTC Out of cycle payment - separate payment calculated if the pharmacy has changes ownership and has missed the LTC monthly payment or pharmacy has technology problems and missed LTC payments
A3/J3   Paid quarterly based on the agreement calculation and number of prescriptions within each pharmacy's claim that were claimed as A3/J3
Qtr Case Mix 3 monthly wash up - calculated as per the pharmacy agreement
S26/S29 Paid quarterly based on the number of prescriptions within the last quarter the pharmacy had dispensed under these two services.
COO” Anything with the above references but also has the additional code of COO Change Of Ownership payments - usually moved from old owner to new owner

Forms


Publications

Claiming Guidelines

Claiming Dates

Procedures Manual

Please note: you should not rely solely on the answers provided here; the contracts applicable to each provider and all relevant legislation must be consulted to determine the full rights & liabilities applicable to any service provider or funder.

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