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Fall 2013 Provider Program Notice

Pharmacy Permit Renewal – Expiration Dec. 31, 2013
MS Medicaid requires that providers be in good standing with their regulatory authorities. Pharmacists are required to update their provider information with license renewal information with Division of Medicaid’s (DOM) fiscal agent or Xerox. Most MS pharmacy permits expire on Dec.31, 2013. Fax the following to Xerox’s Provider Enrollment at 1- 888-495-8169 and not to DOM’s Pharmacy Bureau:

  • Cover sheet with name of pharmacy and/or pharmacy DME, MS Medicaid provider number(s), NPI(s), and a copy of the renewal(s).
  • If you are going to use the pharmacy license to update both, MS Medicaid Pharmacy and DME provider numbers, please indicate that on the cover sheet. Otherwise your only the pharmacy license will be updated.
  • To assure that the information DOM has on hand is accurate, be sure to include the servicing pharmacy’s email address, telephone number and facsimile number on the cover sheet.

Please take time now to verify if your permit expires on Dec. 31, 2013. Be advised that Pharmacy claims may deny after December 31, 2013 IF license renewal information has not been submitted to Xerox. If you fax these documents to DOM, they will be returned to you.

Limited number of CHIP beneficiaries moving to Medicaid Fee for Service (FFS) – Effective Jan. 1, 2014:
In accordance to new federal guidelines, some CHIP beneficiaries will become Medicaid FFS eligible on Jan. 1, 2014. Beneficiary identification numbers for CHIP and Medicaid are the same. When processing a pharmacy claim for a CHIP beneficiary who becomes eligible for Medicaid FFS on 1-1-2014, the following message will be returned to pharmacy providers: Bill Medicaid BIN 610084, PCN DRMSPROD, GROUP SIPPI. Issues call toll-free 800-884-3222.

Preferred Drug List (PDL) Update
DOM’s Preferred Drug List or PDL undergoes an annual review each autumn. The revisions brought about by this annual review will become effective the following Jan. 1. To reference the current PDL, go to Pharmacy, click on PDL and select the MS Preferred Drug document. To view the document in its entirety, go to ‘MS PDL Effective January 1, 2014.’ To reference the preferred/non-preferred additions and deletions, see ‘MS PDL Changes-Provider Notice, effective January 1, 2014.’

We recommend adding this link to your favorites as you will find it very helpful. Look for these documents to be posted on line by Dec. 1, 2013.

Billing changes: Over the counter (OTC) drugs, for beneficiaries residing in long term care facilities
Effective Jan. 1, 2014, over the counter drugs (OTCs) can no longer be billed to MS Medicaid as a point of service (POS) claim for beneficiaries residing in LTC facilities, i.e. NH (nursing homes), ICFMR(intermediate care facilities for the mentally retarded), and PRTFs(psychiatric residential treatment facilities). For these beneficiary populations, DOM’s OTC formulary items are now considered ‘stock items’ and are to be included in the facility’s cost report. DOM’s OTC formulary can be located at the Pharmacy webpage. The only exclusions to this policy are as follows:

  • OTC insulin: bill dually eligible beneficiary’s Medicare Part D plan; for the Medicaid only, bill Medicaid as a POS claim.
  • Pseudoephedrine and Pseudoephedrine combination products limited to agents listed on the OTC formulary: since these agents are classified as controlled substances in MS, for the dually eligible and Medicaid only, bill Medicaid as a POS claim.
  • Guaifenesin/codeine limited to agent(s) listed on the OTC formulary: since this agent is classified as controlled substance in MS, for the dually eligible and Medicaid only, bill Medicaid as a POS claim.

New Pharmacy Prior Authorization (PA) manual form
In accordance to state law passed in the 2013 legislative session, health benefit plans, including Medicaid, are directed to establish a standardized pharmacy prior authorization form. DOM encourages Medicaid providers to use preferred agents whenever possible; most preferred drugs do not require PA. Drugs designated as preferred have been selected for their efficaciousness, clinical significance, cost effectiveness, and safety for Medicaid beneficiaries. Note that there are multiple preferred alternatives for non-preferred drugs.
Before submitting a PA request, remember to check for options not requiring PA at the current PDL which may be referenced at .
To reference the new Medicaid Pharmacy form, go to the Pharmacy web page and click on Prior Authorization. Pharmacy PA FAX line number is 1-877-537-0720.

Be mindful that in order for DOM to be in compliance with state law, submissions on forms used previously can no longer be accepted for Medicaid beneficiaries and will be returned to the prescriber. Look for new form to be posted online by Dec. 1, 2013.

All Prescribers who write prescriptions for MS Medicaid beneficiaries must be enrolled as a MS Medicaid provider
Effective Jan 1., 2014, in accordance with Federal guidelines, prescribers who write prescriptions for Medicaid beneficiaries must be enrolled as Medicaid providers. Prescribers who do not bill Medicaid for professional services, but write prescriptions for Medicaid patients must enroll as an Ordering, Referring, Prescribing (ORP) provider type.
For Pharmacy Point of Sale Claims:

  • Prescription claims with a date written on or after January 1, 2014 must be written by a prescriber who has a valid and active MS Medicaid enrollment which is verified by the prescriber’s NPI number. NPI numbers are validated against the National Plan and Provider Enumeration System Registry (NPPES).
  • Prescriptions written by non-Medicaid providers will post NCPDP Reject ’56-Non Matched Prescriber ID’ with the accompanying message ‘FED LAW REQUIRES ALL MEDICAID PRESCRIBERS ARE ENROLLED AS A MEDICAID PROVIDER. NPI SUBMITTED ON CLAIM MUST BE THE ACTUAL PRESCRIBER ON THE RX, ANY OTHER IS CONSIDERED FRAUD’.
  • If the Prescriber’s NPI number is not enrolled with Medicaid as a valid and/or active provider, then that prescriber will have a grace period of 90 days to enroll.
  • Beginning 1-1-14, first time claims, received for non-Medicaid providers “with a date written” on or after 1-1-2014, will generate letters to these non-Medicaid prescribers with enrollment instructions for MS Medicaid. If these prescribers do not enroll during their 90 day grace period, then their Medicaid prescriptions, on day 91 and thereafter, will deny.
  • Pharmacy claims will not actually start denying until April 1, 2014 and after.

What is the Pharmacist’s Role?

  1. Be sure to enter the correct NPI for the prescriber. This is important because if the NPI number is not enrolled, then a letter, providing enrollment instructions, to the prescriber will be generated. Remember that the NPI on the claim must be the prescriber of the prescription. Any other NPI used is considered fraud.
  2. Remind prescribers to enroll if you continue to see NCPDP Reject ’56-Non Matched Prescriber ID’ on that prescriber’s claims.