Billing Guidance Exceptions for Non-Enrolled Prescribers and Pharmacies
9/19/2022
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Posted by Provider Relations
The New York State (NYS) Medicaid program requires enrollment of all licensed prescribers and pharmacies who serve Medicaid members, including prescribing practitioners identified on pharmacy claims per the Centers for Medicare and Medicaid Services (CMS) and federal regulations. This is applicable to all Fidelis Managed Medicaid members.
Prescriptions written by non-enrolled prescribers or filled at non-enrolled pharmacies will REJECT at the pharmacy, resulting in one of the two following scenarios:
- Reject 889: Prescriber not enrolled in the State Medicaid Program or
- Reject 890: Pharmacy not enrolled in State Medicaid Program
Exception Submission Clarification Codes are available for:
- Unmet needs/services that are unavailable by another enrolled provider or
- One-time Emergency Medical Care and Services (Per Appendix G of the Model Contract) or
- A prescriber who is an intern, resident, or foreign physician who participates in any medical training
If one of the above situations applies, the pharmacy may utilize:
- Submission Clarification Code 55 for Reject 889 (Prescriber)
- Submission Clarification Code 56 for Reject 890 (Pharmacy)
Pharmacists should use their professional judgement when using the override according to the above policy, prescriber's information at hand, and member history available.
Please visit the link below for additional guidance:
Reminder: Pharmacy Billing Guidance Exceptions for Non-Enrolled Prescribers