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.
Background
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.
Questions?
For more information, view these updates from NYS Medicaid:
