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= 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:
