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Reminder: Pharmacy Billing Guidance for Non-Enrolled Unlicensed Prescribers

Audience: Pharmacies

The New York State (NYS) Medicaid program requires enrollment of all licensed providers who serve Medicaid members, including prescribing practitioners identified on pharmacy claims, per the Centers for Medicare & Medicaid Services (CMS) and federal regulations. However, under the Medicaid Provider Enrollment Compendium (MPEC), there are two exceptions to the provider enrollment requirement.

Interns, Residents and Foreign Physicians in Training - Unlicensed Physicians

In accordance with NYS Education Law (NYSED), Article 131 §6526, unlicensed physicians who are residents, interns, and foreign physicians participating in training programs, are authorized to prescribe. NYS Medicaid recognizes the authority under which these unlicensed providers may prescribe; however, these physicians are not eligible for enrollment into the NYS Medicaid program without a license.

MPEC allows unlicensed physicians to provide ordering/prescribing/referring/attending (OPRA) services to NYS Medicaid members. The State Medicaid Agency (SMA) is not required to enroll a provider type, such as unlicensed physicians, for the purpose of complying with 42 of the Code of Federal Regulations (CFR) §455.410(b) or §455.440 when the provider type is ineligible to enroll in the NYS Medicaid Program.

Guidance and Billing

Additional guidance regarding claim submission for prescriptions written by unlicensed physicians can be found in articles within both the December 2018 and May 2019 issues of the Medicaid Update.

Documentation

Records should be created and maintained supporting the issuance of any prescriptions issued to a NYS Medicaid enrollee by any unlicensed prescriber. This requirement applies to all residents, interns and foreign physicians who participate in any medical training program. The documentation must include the National Provider Identifier (NPI) of the prescriber and NYS Medicaid provider who is responsible for supervising the prescribing unlicensed resident, intern or foreign physician in a training program.

All records related to the issuance of a prescription by non-enrolled prescribers are subject to production upon request by NYS, including but not limited to, by NYS Department of Health (DOH), Office of the Medicaid Inspector General (OMIG), Office of the State Comptroller (OSC) and the NYS Office of the Attorney General.

Out-of-State Licensed Prescribers

Under federal regulations, all ordering or referring physicians (ORPs), or other professionals, must be enrolled in the NYS Medicaid program. However, the MPEC allows for payment of prescription claims prescribed by out-of-state (OOS) licensed physicians or ORPs under limited circumstances. Please note: Federal regulations and NYS Medicaid policy require NYS Medicaid program enrollment for prescribers who do not meet the exceptions below, in order for their claims to be valid and enforceable against the NYS Medicaid program.

Guidance

The following billing guidance applies to OOS licensed prescribers who are either 1) enrolled in Medicare with an "approved" status or 2) are enrolled in another state's Medicaid Plan. The prescription must be for:

  •  single instance of emergency medical care or order for one Medicaid member over a 180-day period, or
  • multiple instances of care provided to one Medicaid member when the services provided are more readily available in another State over a 180-day period; and
  • the NPI of the prescriber must be entered on the claim form; and
  • the claim represents an item provided; and
  • the claim represents services covered under the NYS Medicaid program; and
  • based upon the prescription, the item is furnished by a pharmacy, pursuant to a prescription written by an individual practitioner in an institutional setting at an OOS practice location (i.e., located outside the geographical boundaries of the NYS Medicaid program).

Pharmacy Billing

Effective October 4, 2022, in accordance with the above policies, the following claim submission overrides may be used:

  • Prescriptions must be submitted with the NPI of the prescriber.
  • Pharmacy claims will initially reject for National Council for Prescription Drug Programs (NCPDP) Reject code "889". This means the prescriber is not enrolled in NYS Medicaid.
  • To override above rejection for the unlicensed resident, intern or foreign physician in a training program or OOS prescription situations described above:
  • Resubmit claim with PA Type code 01, PA number 3333 to get paid as an override claim
  • Pharmacists should use their professional judgement when using the above override according to the above policy, prescriber's information at hand, and member history available.
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