New Physician Dispenser Policy

These conditions apply as follows:

• Practitioners that choose to dispense prescription medications to their patients will be eligible to bill these medications through a medical claim form and will be reimbursed at actual invoice cost for the drug dispensed or under the terms of the provider contract.
• Providers may not submit an office visit claim for the sole purpose of dispensing a drug that the member can obtain at a New York State Medicaid enrolled pharmacy.
• Practitioners practicing within their scope of practice that dispense prescription medications directly to patients are not considered a pharmacy—and therefore are NOT eligible for Medicaid enrollment or reimbursement as a pharmacy provider.

Please see the following information regarding our claim submission process.

Tips for Claims Submission

The following tips will assist providers with verifying benefits, navigating prior authorizations, and submitting claims for drug administration:

1. Determine if the drug is covered as a medical or pharmacy benefit and if there are any applicable prior authorization requirements.

2. Accurately complete and submit a prior authorization request (if required)

   a. If required, include a Letter of Medical Necessity that outlines the patient’s medical history and the rationale for therapy.

   b. Consider attaching a copy of the package insert and any other clinical documentation.

   c. Ensure medical records include full and proper documentation of patient’s history, prior therapy, and rationale for treatment.

3. Determine any special distribution requirements (e.g., free to the facility via a NYS benefit, mandatory use of a specific specialty pharmacy, or requirements to buy-and-bill). 4. Specify the proper number of units on the Claim Form.

4. Specify the proper number of units on the Claim Form.

5. Verify that all identification numbers and names are entered correctly.

6. Use correct ICD-10-CM codes, including fourth or fifth digits.

7. Indicate the 11-digit National Drug Code (NDC) on the Claim Form.

8. Verify the use of proper HCPCS and CPT codes.
   a. Example: If the drug has been delivered in the patient’s name from a specialty pharmacy or was received at no charge to the facility, enter the appropriate administration CPT code (i.e., 96372) and enter the appropriate HCPCS code (i.e., J0401) with a charge of $0

9. If applicable:
   a. Use the appropriate modifier code
   b. Indicate the corrected claim details to distinguish and avoid interpretation as a duplicate claim
   c. Confirm that the correct revenue code is used with the appropriate supporting HCPCS code

10. File the claim in a timely fashion

Important Reminders

• Providers should administer drugs and biologicals in the most cost-effective and clinically appropriate manner.
• Providers will utilize the most appropriately sized single-use vial or combination of single-use vials to deliver the ordered dose of medication and minimize waste.
• Reimbursement for drugs and biologicals will be made in accordance with the provider’s contract.

More Information

• Healthfirst Provider Manual

Questions?

If you have any questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am-5:30pm.