September 18, 2022

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.

Override process

UnitedHealthcare provides overrides in specific circumstances for non-enrolled prescribers and pharmacies. Below is the rejection and resolution process:

Non-enrolled prescriber exceptions

Reject: 71
Messaging: Prescriber not enrolled in NYS Medicaid ID PLEASE USE SCC42 for exceptions only
Resolution: Submission clarification code = 42
Submission clarification code = 02 (1st), 06 (Addl), 10 (Boost)
Prof Service Code = MA
Override eligibility Pharmacists, residents, interns, foreign MDs, foster care members, discharges, emergency and urgent prescribers

Non-enrolled pharmacy exceptions

Reject: 50
Messaging: Pharmacy not enrolled in NYS Medicaid
Resolution: Pharmacy Help Desk at 877-305-8952
Override eligibility: Out of state discharges and emergencies, foster care members

For additional information, view the NYS Medicaid update from April 2022.


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:

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