Medicaid to implement single Pharmacy Benefit Administrator for all pharmacy claims on July 1
On July 1, the Mississippi Division of Medicaid (DOM) will implement a single Pharmacy Benefit Administrator (PBA) to streamline and enhance the processing and management of pharmacy claims for all Medicaid members, including those enrolled in MississippiCAN.
Operated by Gainwell Technologies, the PBA will also assume all pharmacy prior authorization responsibilities for drugs submitted on pharmacy claims. DOM will continue to require the use of the Universal Preferred Drug List (PDL). This decision comes after careful consideration and evaluation of various factors aimed at enhancing efficiency and transparency in the Medicaid delivery system.
Members should notice no disruption in their care if providers are prepared for this change.
WHAT YOU NEED TO KNOW AND DO
Pharmacy Providers:
Billing Directions
Pharmacy providers must ensure their pharmacy software is configured to submit NCPDP D.0 pharmacy claims, with dates of service of 7/1/2024 and thereafter, for all Medicaid members (fee-for-service, MSCAN and MSCHIP) to Gainwell using the following billing values:
- BIN – 025151
- PCN – DRMSPROD
Retroactive Billing Directions
To bill pharmacy claims with dates of service prior to 7/1/2024, providers must ascertain which Coordinated Care Organization (CCO) in which the beneficiary was enrolled on that date and submit to that CCO’s PBM. For example, if the member was enrolled with Molina, the claim (s) should be submitted to CVS Caremark. The MSCAN and MSCHIP BIN/PCN values in effect prior to 7/1/2024 should be used. Retroactive billing will be possible for claims with dates of service a year back from 6/30/24.
Pharmacy Help Desk
The Gainwell pharmacy call center phone number is 833-660-2402. This is a direct line to the Gainwell pharmacy help desk to aid with pharmacy claims and pharmacy prior authorizations. All pharmacy claims and prior authorization assistance should be directed to this number.
Weekly Remittance Advice (RA) Statements
Pharmacy providers will continue to receive weekly payment for claims and all claims (fee-for-service, MSCAN and MSCHIP) will appear on a single RA.
Reimbursement change for CHIP claims
MSCHIP claims will be reimbursed using the same methodology used for fee-for-service and MSCAN claims.
Prescribing Providers:
DOM requires most prior authorization (PA) requests be signed/submitted by prescribers.
Prescribers and their administrative staff must submit all requests to Gainwell on July 1, 2024, and thereafter. The preferred method of submission is via the MESA Portal for Providers.
PA requests may also be faxed to Gainwell at 866-644-6147. If PA assistance is needed providers can call 833-660-2402.
General Prior Authorization Instructions can be found on DOM’s website at https://medicaid.ms.gov/wp-content/uploads/2022/09/DOMPriorAuthorizationInstructions-Gainwell.pdf.
PA reconsideration requests and appeals can also be sent to Gainwell directly via fax at 866-644-6147. More details regarding the PA transition will be shared before July 1, 2024.
Find more Late Breaking News at: https://medicaid.ms.gov/late-breaking-news/
