September 18, 2022

New York Medicaid: Changes to practitioner dispensing billing process

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

Reject: 71
Messaging: Prescriber not enrolled in NY Medicaid ID
Resolution: Pharmacy help desk at 877-305-8952
Override eligibility Interns, residents, foreign MDs, emergency room prescribers, discharges, foster care

For COVID related billing such as Paxlovid®, testing kits, vaccine, vaccine counseling, etc

Reject: E5
Messaging: M/I Professional Service
Resolution:

Submission clarification code= 42

Submission clarification code= 02(1st), 06 (Addlt), 10 (Boost)

Prof Service Code= MA

Override eligibility: Pharmacists and other non-enrolled prescribers where allowable by state or federal guidance

Non-enrolled pharmacy

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

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:

PCA-22-02839-C&S-News
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