Elderly Pharmaceutical Insurance Coverage (EPIC) Provider Page/FAQ's
Provider Eligibility Requirements
To participate in the New York State EPIC/American Indian Health (AIH) programs, providers must:
- Be enrolled in New York State Medicaid, including out-of-state pharmacies dispensing in NYS.
- Hold an active NYS Medicaid license and credential.
- Possess a valid New York State registration number.
How to obtain a Provider Agreement Application
NYS Elder law §253 Utilization of out-of-state provider pharmacies; necessity and convenience.
In counties having a population of seventy-five thousand or less that are in proximity to the state boundary and which are determined by the commissioner of health to be not adequately served by provider pharmacies registered in New York, and in Fishers Island in the town of Southold, Suffolk county, the commissioner may approve as provider pharmacies, pharmacies located in New Jersey, Connecticut, Vermont, Pennsylvania or Massachusetts. Such approvals shall be made after:
- consideration of the convenience and necessity of New York residents in the rural areas served by such pharmacies,
- consideration of the quality of service of such pharmacies and the standing of such pharmacies with the governmental board or agency of the state in which such pharmacy is located,
- the commissioner shall give all licensed pharmacies within the county notice of his or her intention to approve such out-of-state provider pharmacies, and
- the commissioner has held a public hearing at which he or she has determined factually that the licensed pharmacies within such county are not adequately serving as provider pharmacies.
Provider FAQs
General Enrollment Frequently Asked Questions
Q: How long does it take to become a participating EPIC provider?
A: The average processing time is 7–10 business days.
Q: How will I be notified about the status of my Provider Agreement application?
A: You will receive a determination letter via mail.
Q: Can I enroll if my pharmacy Medicaid application is pending?
A: No. Pharmacies must be actively enrolled with New York State Medicaid to participate.
Q: Can mail-order pharmacies participate with NYS EPIC/AIHP?
A: Yes, provided the pharmacy meets the above requirements.
Q: How do I cancel my EPIC provider enrollment?
A: Submit a written request and fax it to 1-888-656-4156, including the requested termination date.
Outstanding Balances FAQs
Q: I received a letter stating that I have an outstanding balance owed to New York State EPIC. What does this mean?
A: The outstanding balance is the result of previously processed claim reversals, which created an amount owed to New York State EPIC. Please note that this balance is more than 90 days past due.
Q: How can I resolve this outstanding balance?
A: Payment can be made by mailing a check to the address below:
New York State EPIC Program
Attn: Finance Collection
P.O. Box 15018
Albany, NY 12212
Q: Can I obtain a list of the claims that were reversed?
A: Yes. A detailed list of reversed claims is available upon request.
Q: Can a payment arrangement be made?
A: Please contact the New York State EPIC Provider Helpline at 1-800-634-1340.
Provider Change of Ownership FAQs
Q: How does a pharmacy continue processing while undergoing a change of ownership?
A: Send a copy of the profile page from the National Council for Prescription Drug Programs (NCPDP) website showing a valid extension date and fax the information to 1-888-656-4156.
Q: What should I do if a claim is rejected because the pharmacy is no longer contracted with NYS EPIC?
A: Contact the EPIC Provider Helpline at 1-800-634-1340 and select option #2.
Provider Financial FAQs
Q: How can I access the provider Financial Portal?
A: Providers seeking to access the Financial Portal to submit requests for EFT/ERA updates must register with the User Administration Console (UAC)
Note: A PIN will be sent via mail.
Q: How can I update my banking information?
A: Providers seeking to access the Financial Portal to submit re
Providers seeking to access the Financial Portal to submit requests for EFT/ERA updates must register with the User Administration Console (UAC)
Q: How can I obtain a copy of the 835 Electronic Remittance Advice?
A: Log in to https://ciam.primetherapeutics.com/ to access the 835 Remittance Advice.
Q: How are payments released from EPIC/AIHP?
A: Electronic Funds Transfer (EFT) payments are sent electronically to the banking information provided in the Financial Portal
Provider Point-of-Sale FAQs
Q: Who should I contact for claim denials or rejections?
A: Contact the EPIC Provider Helpline at 1-800-634-1340, option #2.
Q: What information is required when contacting the Provider Helpline for assistance?
A: For HIPAA compliance, EPIC/AIHP requires the following:
- Member Identification Number
- Member Full Name
- Member Date of Birth
- Pharmacy NPI Number
Q: What is the filing limit to submitting a point-of-sale claim?
A: Pharmacies have 365 days to submit claims. If rebilling older claims is not possible at the store level, please contact your corporate office or pharmacy helpdesk for assistance.
Q: What is the EPIC group name, BIN, and PCN?
Plan Name/Group Name: NYEPIC
BIN: 012345
PCN: P024012345
Q: What is the AIHP group name, BIN, and PCN?
Plan Name/Group Name: NYAIH
BIN: 011925
PCN: P023011925
