Pharmacy/Prescriber Medicaid Managed Care Network & Medicaid Provider Enrollment. February 14, 2018
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1 Pharmacy/Prescriber Medicaid Managed Care Network & Medicaid Provider Enrollment February 14, 2018
2 2 Pharmacy/ Prescriber Enrollment Enrollment Effective Date Pharmacy/Prescriber FAQ s Contract Amendment Notice of Amendment Amendment Language Terminations Questions
3 3 Pharmacy/Prescriber Enrollment MCOs should be utilizing both the Medicaid FFS Active Provider Listing and the Medicaid Managed Care FFS Pending Provider Listing lists to identify their network providers who are not enrolled or have an application pending. These lists will be updated on approximately the 15 th of the month. The updated Medicaid FFS Active Provider Listing has been posted on Health Data NY at: Listing/keti-qx5t The Medicaid FFS Pending Provider Listing will available on emedny at:
4 4 Enrollment Effective Date Practitioners (Prescribers): The effective date is backdated 90 days prior to receipt of application for enrollment as long as during such period, the provider is licensed, and if required enrolled in Medicare. This allows claims payment for services provided in fee for service in accordance with the Medicaid s 90 day claim submission regulation. Example: A physician who is licensed as of January 1, 2018, and whose enrollment was received on April 1, 2018, will have an enrollment effective date of January 1, Businesses (Pharmacies): The enrollment effective date is the date the application is received. This may be, on a case by case basis, backdated for reasons such as ownership change effective dates and claims payment.
5 5 Pharmacy/Prescriber FAQs FAQs and this PowerPoint will be posted in the near future at: At the above link you will be able to search the Pharmacy/Prescriber FAQ s by selecting the Pharmacy/Prescriber Category A Sample of FAQ topics that are covered: Q. If a script for a prescription drug is to be filled after 1/1/18 that is written by a prescriber without a MMIS (Medicaid ID) number, is the plan supposed to reject that claim; if this is the case, when should plans start rejecting claims from prescribers that are not enrolled? A. Claims for drugs prescribed by a non-enrolled provider, after 1/1/2018, can be adjudicated; however, the plan should have a process in place to notify the non-enrolled prescribers that they must enroll into the Medicaid program for a member to continue receiving their prescriptions without an interruption in therapy.
6 6 Pharmacy/Prescriber FAQs (cont d) Q. How do we handle out of network, urgent/emergent pharmacy requests for members that are outside of our immediate service area who go to a pharmacy that is not enrolled in Medicaid? A. Members and prescribing providers are encouraged to contact the MCO and obtain direction to an in-network pharmacy, if available. In the event no in-network pharmacy is available, MCO s can provisionally credential the pharmacy and/or prescriber so that the medication can be dispensed, on a condition that such pharmacy and/or prescriber submits an enrollment application with NYS Medicaid. Q. NYS Medicaid only enrolls licensed practitioners. How should claims be paid for unlicensed residents, interns and foreign physicians that are in training programs that are legally authorized to write prescriptions, per NY Education Law under the supervision of a NY State Medicaid enrolled physician? A. MMC plans are expected to have system overrides and edits in place to allow for the payment of claims for items prescribed by unlicensed residents, interns and foreign physicians in training programs.
7 7 Pharmacy/Prescriber FAQs (cont d) Q. What are the enrollment requirements for the in-state and out-of-state pharmacies? A. All in-state and out of state pharmacies that provide services to Medicaid, CHIP and Medicaid Managed Care members are required to enroll in the New York State Medicaid Program pursuant to the 21 st Century Cures Act. This requirement also applies but is it not limited to: specialty, mail order, infusion and long-term care pharmacies; as well as out of state pharmacies and those pharmacies providing unique or limited distribution drugs. For instructions and required documentation needed for enrollment please visit: Plans should have a process in place to notify the non-enrolled pharmacy providers that they must enroll into the Medicaid program for a member to continue receiving their prescriptions without an interruption in therapy.
8 8 Pharmacy/Prescriber FAQs (cont d) Q. Do ordering, referring, prescribing providers that are non-par with plans but service Medicaid beneficiaries need to be enrolled? A. Section 5005(b)(1) of the 21st Century Cures Act amended Section 1902(a) of the Act now requires, as a condition for participation in the Medicaid program, all ordering, prescribing, and referring (OPRA) providers be enrolled in the state Medicaid programs. Effective 01/01/2018 this requirement includes participating OPRA providers of Medicaid Managed Care (MMC) plans. Enrollment in the Medicaid program as a non-billing provider does not require the provider to participate in any MMC plans or the Medicaid Fee-for-Service (FFS) program, however, it does allow the member to utilize their Medicaid coverage for prescriptions, ordered and referred services. MMC plans are expected to verify these providers are enrolled in NYS Medicaid.
9 9 Pharmacy/Prescriber FAQs (cont d) Q. Are there exemptions, waivers or streamlined enrollment procedures for licensed non-resident pharmacies that only fill prescriptions for members participating in the State s Medicaid Managed Care program? A. There are no exemptions or waivers. Non-resident pharmacies that fill prescriptions for members participating in the State s Medicaid Managed Care program must enroll. However, the process is streamlined for those pharmacies whom submit an enrollment and check the Managed Care Only (Non-Billing) box on the enrollment form. Those pharmacies will not need to submit an electronic transmitter identification number (ETIN) or an Electronic Fund Transfer (EFT) form, and will not need additional reviews that are typical for FFS Billing Pharmacy enrollment approval.
10 10 Pharmacy/Prescriber FAQs (cont d) Q. Many plans contract for pharmacies through a Pharmacy Benefit Manager (PBM). For pharmacy providers that do not apply for a Medicaid ID, do they need to be removed from the network, or can plans just deny the claims with the message Not a NYS Medicaid provider; please contact the Plan? A. NYS Medicaid recognizes that many plans contract with PBMs for their specific networks. These networks might be contracted through the PBM to provide services to many different plans, commercial and governmental. It is also recognized that individual pharmacies within a PBM s specific network might choose to not accept the contract amendment requiring enrollment with NYS Medicaid. DOH will be providing guidance to MCOs on the next steps for network termination and appropriate remittance messages to providers who refuse to accept the contract amendment by 7/1/2018.
11 11 MCO-Provider Contract Amendment Pursuant to a 21 st Century Cures Act Section 5005, no later than 7/1/2018, MCOs must amend contracts with providers(pharmacies & prescribers) to include a provision that requires providers to enroll with the State s Medicaid program. If, however the providers fail to enroll, such providers shall be terminated from participating as a provider in any network of the MCO that serves individuals eligible to receive Medicaid and CHP. The Department suggests that this amendment can be done via notice as a unilateral amendment because the Standard Clauses include a provision that requires all parties to comply with all applicable Federal and State laws, rules and regulations.
12 12 Notice of Amendment The notice of amendment should include an opt out provision allowing the provider who does not want to be bound by this provision an opportunity to terminate the contract. If provider chooses to opt out, the provider is terminating the contract. Therefore, no further notice of termination or hearing rights need to be provided by the MCO to the provider. For this type of termination, no transitional care is required. However, providers who choose to opt out should follow the applicable licensure laws regarding the transfer of patient care to another provider.
13 13 Amendment Language The Department suggests the following amendment language: The provider furnishing items and services to, or ordering, prescribing, referring, or certifying eligibility for, services for individuals eligible to receive Medicaid and CHP agrees to enroll in the NYS Medicaid Program by completing and filing the designated enrollment application and providing the required information necessary for enrollment. In the event a provider is terminated from, not accepted to, or fails to submit a designated enrollment application to, the NYS Medicaid Program, provider shall be terminated from participating as a provider in any network of the MCO that serves individuals eligible to receive Medicaid or CHP. If a provider did not exercise the right to opt out and, therefore, accepted the amendment but the provider failed to enroll in the NYS Medicaid program subsequent to 7/1/2018 contract amendment deadline, MCOs shall initiate termination. MCOs shall send a notice of termination to such non-enrolled providers pursuant to the requirements of PHL 4406-d (2). Transitional care required in PHL 4403 (6) (e) (1) will apply.
14 14 Terminations CMS has advised States that it does not recommend termination of providers who did not enroll as of January 1, 2018, given that it would cause access to care issues. At this time, MCOs should not be initiating terminations relating to failure to enroll in Medicaid. MCOs should be taking the following steps now: Send out provider contract amendment Check enrollment and pending enrollment data to track compliance Identify and reach out to providers who have not complied The Department will be providing further guidance and recommendations regarding additional compliance measures MCOs may utilize prior to termination.
15 Are there any questions? FAQs are available, along with other resources, at: Or contact us: Mainstream, HARP and HIV-SNP: for general managed care questions, the MCO Outreach Survey, and the active list of Medicaid FFS providers, the Bureau of Managed Care Fiscal Oversight at Managed Long Term Care: for general managed care questions, For general provider enrollment questions, the Bureau of Provider Enrollment at emedny Call Center: (800) To subscribe to the Pharmacy Policy listserv,
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