Pharmacy billing instructions during a disaster or emergency

Effective Jan. 1, 2015, during states of officially declared emergencies please use the following pharmacy emergency supply procedures, for fee-for-service (FFS) Medicaid, MississippiCAN, and the Children’s Health Insurance Program (CHIP).

Payer – MS Medicaid: Pharmacy fee for service claims only.
72 hour supply is to be used any time a PA is not available and when Rx must be filled.
Pharmacist should use professional judgment regarding whether or not there is an immediate need every time 72 hour option is used.

Contact: Pharmacy PA unit toll-free 877-537-0722; fax 1-877-537-0720

Billing instructions:

1. Input a value of ‘3” in the level of service (Field 418-DI);
2. Input a value of ‘3” in the day supply field (Field 418-DI);
3. Quantity submitted in the Quantity dispensed field (Field 442-E7) should not exceed the quantity necessary for a three-day supply according to the direction for administration given by prescriber.
4. For unbreakable packaging, including but not limited to, inhalers, antibiotic suspensions or otic drops, a pharmacy should follow the same directions for the 72 hour emergency supply including entering the full quantity dispensed and either entering the correct days’ supply or a ‘3’ day supply.
5. If applicable, pharmacist is to contact prescriber for the reminder of the prescription.

Payer – MissisippiCAN: Magnolia Health Plan and CHIP
Pharmacies calling in for 72 hour emergency override supply have the ability to insert the override on their end without a call (for non-preferred, prior authorization required, and step therapy required rejections).

Contact: PBM is US Script, Inc. Pharmacy Help Desk toll-free 800-460-8988

Pharmacies should submit:

• ‘8’ in “Prior Authorization Type Code” (Field 461-EU)
• ‘3’ in “Days’ Supply” in the claim segment of the billing transaction (Field 405-D5)
• The quantity submitted in “Quantity Dispensed” (Field 442-E7) should not exceed the quantity necessary for a three-day supply according to the directions for administration given by the prescriber. If the medication is a dosage form that prevents a three-day supply from being dispensed, e.g., an inhaler, it is still permissible to indicate that the emergency prescription is a three-day supply, and enter the full quantity dispensed.

Payer – MississippiCAN: United Healthcare and CHIP United Healthcare
Dispense a 72 hour emergency medication supply via an override when our prior authorization phone line is not available.

Contact: PBM is OptumRx Pharmacy Help Desk toll-free 877-305-8952

Emergency supply is limited to one 72 hour supply per 365 days per drug. If medication can’t be dispensed as an exact 72 hour supply, dispense the minimum quantity as a 72 hour supply. Examples include, but are not limited to: metered dose inhalers, nasal sprays, topical preparations and powders for reconstitution.

Please include following information when submitting claims for a 72 hour supply:

• Prior Authorization Type code (Field 461-EU) = 8
• Prior Authorization number submitted (Field 462-EV) = 120
• Day Supply in the claim segment of the billing transaction (Field 405-D5) = 3

Please note, that when the declared emergency announcement is made, the fields noted above will be opened for the specified time period. Pharmacy providers are advised to use professional judgment in emergency situations.

The Division of Medicaid may conduct audits after such events to ensure appropriate care was taken in dispensing medications for affected beneficiaries. Providers and beneficiaries residing and/or receiving care not in an evacuation area must have documentation on file to justify rationale for early/excess fills. Medicaid monies may be recouped if supporting documentation is not found.