New York Medicaid: Changes to practitioner dispensing billing process
Last updated: October 28, 2022
Effective Sept. 1, 2022, Medicaid Managed Care (MMC) plans will deny payment to pharmacies that are not enrolled as a pharmacy provider for fee-for-service (FFS) Medicaid. This includes practitioners, practicing within their scope of practice, who dispense medications directly to their patients. These practitioners are not considered a pharmacy, and therefore are NOT eligible for Medicaid enrollment or reimbursement as pharmacy providers.
As a result, practitioners will no longer be able to bill the pharmacy benefit. NYS Medicaid enrolled practitioners are eligible to bill medications dispensed to a patient via the medical claim format.
UnitedHealthcare provides overrides in specific circumstances for non-enrolled prescribers and pharmacies. Below is the rejection and resolution process:
Non-enrolled prescriber exceptions
Prescriber not enrolled in NYS Medicaid ID PLEASE USE SCC42 for exceptions only
Submission clarification code = 42
Submission clarification code = 02 (1st), 06 (Addl), 10 (Boost)
Prof Service Code = MA
Pharmacists, residents, interns, foreign MDs, foster care members, discharges, emergency and urgent prescribers
Non-enrolled pharmacy exceptions
Pharmacy not enrolled in NYS Medicaid
Pharmacy Help Desk at 877-305-8952
Out of state discharges and emergencies, foster care members
New York State Education (NYSED) Law, Article 137 §6807, authorizes practitioners who are authorized to prescribe to dispense medications directly to their patients. Authorized practitioners have been able to bill the pharmacy benefit or the medical benefit when dispensing medications directly to their patients.
For more information, view these updates from NYS Medicaid: