New York State Medicaid Update - February 2024 Volume 40 - Number 2
In this issue …
- Pharmacy
- Policy and Billing Guidance
Reminder: Pharmacies Submitting Medicaid 340B Drug Claims
New York State (NYS) Medicaid continues to accept appropriately submitted claims for 340B purchased drugs. Federal law 42 United States Code (USC) 256b(a)(5)(A)(i) prohibits duplicate discounts, such that drug manufacturers are not required to provide a discounted 340B price and a NYS Medicaid drug rebate for the same drug. To prevent duplicate discounts, NYS Medicaid exclusively uses claim level identifiers on either National Council for Prescription Drug Programs (NCPDP) or Professional/Institutional claim types (837P/837I) on eligible 340B purchased claims. Information on how outpatient clinics bill for 340B drugs can be found in the Clarification of Previous Guidance: New York State Medicaid Fee-for-Service Coverage of Practitioner Administered Drugs article published in the July 2022 issue of the Medicaid Update.
Pharmacy providers must comply with NYS Medicaid policy for 340B drug claims, as outlined in the NYRx the NY Medicaid Pharmacy Program - Pharmacy Manual Policy Guidelines and Medicaid Update articles. All NCPDP-submitted 340B-purchased drug claims (when NYS Medicaid is primary payor) must be submitted with claim level identifiers and at actual acquisition cost. Providers should refer to the NYRx the NY Medicaid Pharmacy Program - Pharmacy Manual Policy Guidelines for requirements when NYS Medicaid is secondary payor. Claim level identifiers are required on eligible 340B purchased drug claims for NYS Medicaid members.
Through monitoring real-time claims, NYRx has identified two trends in pharmacy submitted 340B drug claims:
- Ingredient cost submitted exceeds 340B ceiling price
- Invalid codes submitted for 340B pharmacy drugs
The 340B ceiling price refers to the maximum amount that a manufacturer can charge the covered entity for the purchase of a 340B drug. A claim submitted to NYS Medicaid that is higher than the 340B ceiling price will be denied. Claims that are denied must be resubmitted with the correct ingredient cost. Alternatively, the pharmacy may dispense a non-340B drug and remove the claim level identifiers and submit at the usual and customary charge.
Claims for 340B drugs submitted to NYS Medicaid via the NCPDP D.0 format must also adhere to the following:
- must be properly identified as 340B for both fee-for-service (FFS) members and Medicaid Managed Care (MMC) enrollees; and
- submitted at the 340B acquisition cost by invoice to the provider for FFS members and MMC enrollees, net any manufacturer discounts and/or other price reductions.
The following is additional information on NYS Medicaid 340B drug claim edits:
*The Medicaid Eligibility Verification System (MEVS) Denial Code for a transaction is returned within the Additional Message Info (526-FQ) and indicates the MEVS error for rejected transactions.
| NYRx Edit | NYRx Description | NCPDP Reject Response | Additional Information and How to Resolve | Resources |
|---|---|---|---|---|
| 02276 | Submitted Ingredient Cost Exceeds Ceiling Price | 78 - Cost Exceeds Maximum *Additional MEVS Denial code: 708 - Exceeds NY Allowed Maximum. |
Pharmacy has identified the eligible claim as dispensing a 340B drug. The pharmacy must submit the ingredient cost at their 340B price in field 409-D9, with no fees added. |
|
| 02275 | Invalid Codes Submitted For 340B Pharmacy Drugs | 34 - M/I Submission Clarification Code *Additional MEVS Denial Code: 734 - Invalid Combination of Values for 340B Drug. |
Pharmacy has identified the eligible claim as dispensing a 340B drug with a claim level identifier of "20" in field 420-DK but has not submitted the claim with a Basis of Cost Determination Code of "08" in field 423-DN as required for a 340B claim, or the pharmacy submitted the Basis of Cost of "08", but did not enter a "20" in field 420-DK. Pharmacy should resubmit claim with actual acquisition cost and "08" in the Basis of Cost field. |
|
Please note: All 340B claims are subject to audit and investigation; in addition, claims improperly identified as 340B and/or claims with unsubstantiated Acquisition Cost may be considered fraudulent claims.
Important NYRx Phone Numbers:
- eMedNY - Claims billing and ePACES assistance: (800) 343-9000
- Magellan Rx Management, LLC - Prior authorization (PA) requests, emergency 72-hour supply requests, clinical criteria questions and NYRx programs: (877) 309-9493
- Medical supplies and procedure code limits: (800) 342-3005
- Enteral nutrition PA: (866) 211-1736, Option 1
General Resources:
- NYRx, the NYS Medicaid Pharmacy program
- Medicaid Update
- NYRx, the Medicaid Pharmacy Program Preferred Drug List
- NYRx the NY Medicaid Pharmacy Program - Pharmacy Manual Policy Guidelines
- New York State Department of Health - List of Medicaid Reimbursable Drugs
- eMedNY Prospective Drug Utilization Review/Electronic Claims Capture and Adjudication ProDUR/ECCA Provider Manual (NCPDP Reject Response/MEVS))
Questions
Questions regarding this policy should be directed to NYRx@health.ny.gov.
Reminder: Pharmacy Coverage Includes Over the Counter Naloxone
New York State (NYS) Medicaid covers naloxone over the counter (OTC) when prescribed by the practitioner of a NYS Medicaid member or dispensed to a NYS Medicaid member in compliance with the State-issued naloxone standing order. Information regarding the naloxone standing order can be found in the NYS Department of Health (DOH) Non-Patient Specific Prescription for Naloxone with Pharmacy Dispensing Protocol document.
To comply with NYS laws, regulations, and NYS Medicaid policy, a pharmacy must submit a claim and dispense naloxone OTC pursuant to a fiscal order or via a standing order. When dispensing naloxone OTC via a standing order, all the following must apply:
- a NYS Medicaid member had specifically requested the item on the date of service (DOS); or
- a pharmacist-initiated dispensing per a determination of need/risk on DOS for a NYS Medicaid member; and
- a pharmacy submits one course of therapy (two doses) with no refills; and
- the drug item(s) are dispensed according to:
- Food and Drug Administration (FDA) guidelines;
- NYS laws, rules, and regulations; and
- NYS Medicaid Policy.
Billing a Standing Order:
- Enter a value of "5" in the Prescription Origin Code field 419-DJ to indicate pharmacy dispensing;
- Enter a value of "99999999" in the Serial Number field 454-EK;
- Submit the prescriber identification field 411-DB with the NPI of the authorizer of the standing order;
- Maintain documentation that includes:
- NYS Medicaid member consent, and
- modality of the NYS Medicaid member request (in pharmacy or by telephone), or
- pharmacist determination of need/risk, and
- date and time of either:
- the request of the NYS Medicaid member; or
- the pharmacist need/risk evaluation.
Questions and Additional Information:
- NYRx claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
- NYRx Pharmacy coverage and policy questions should be directed to the NYS Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
- Naloxone standing order specific questions should be directed to naloxonepharmacy@health.ny.gov.
Update for Long-Term Care Pharmacy Providers on Short Cycle Billing of Pharmacy Claims
Long-term care (LTC) pharmacy providers must submit short cycle claims with the appropriate National Council for Prescription Drug Programs (NCPDP) Submission Clarification Code (SCC) value in field 420-DK (see Table 2) when submitting claims for NYS Medicaid members in LTC facilities, for quantities of 14 days' supply or less. Short cycle claims must include the appropriate value as described in Table 2 for fee-for-service (FFS) members who reside in a Private Skilled Nursing Facility, Public Skilled Nursing Facility, Private Health Related Facility, or Public Health Related Facility, as indicated by a "NH" Restriction Exception (RE) code on eligibility response for the NYS Medicaid member. Additionally, the appropriate value in Table 2 must be included on short cycle claims for Medicaid Managed Care (MMC) enrollees who reside in a facility when a RE code of N1 [Regular Nursing home (NH)], N2 (AIDS NH), N3 (Neuro-Behavioral NH), N4 [Traumatic Brain Injury (TBI) NH], N5 (Ventilator Dependent), or N6 (NH-any type), returns on the eligibility response for the NYS Medicaid member.
This guidance supersedes previous guidance found in the following Medicaid Update articles:
- Expansion of Guidance for Long-Term Care Pharmacy Providers on Short Cycle Billing of Pharmacy Claims article published in the November 2021 issue of the Medicaid Update
- Reminder: Long Term Care Pharmacy Providers Will Identify Fee-for-Service Short Cycle Pharmacy Claims article published in the July 2020 issue of the Medicaid Update
- Changes to Medicaid FFS Pharmacy Reimbursement To Be Implemented February 22, 2018 article published in the January 2018 issue of the Medicaid Update
| EMedNY Edit Number/Message | "02322", Missing/Invalid SCC for days' supply 14 or less |
|---|---|
| NCPDP Response Code/Description | "34", Missing/Invalid SCC |
| Valid Values | Short Name Description | Long Name Description |
|---|---|---|
| 06 | START DOSE | STARTER DOSE |
| 10 | MT PLN LMT | MEETS PLAN LIMITATIONS (the pharmacy certifies that the transaction is compliant with program policies and rules that are specific to the particular product being billed) |
| 14 | SHRTLOALTC | SHORT-FILL (leave of absence from LTC) |
| 17 | REMANAFTEK | REMAINDER AFT EMERGENCY KIT |
| 21 | LTC14DAYLS | FOURTEEN DAYS OR LESS NOT APPLICABLE (fourteen days or less dispensing is not applicable due to CMS exclusion and/or manufacturer packaging may not be broken or special dispensing methodology) |
| 22 | LTC7DAY | SEVEN DAY SUPPLY |
| 23 | LTC4DAY | FOUR DAY SUPPLY |
| 24 | LTC3DAY | THREE DAY SUPPLY |
| 25 | LTC2DAY | TWO DAY SUPPLY |
| 26 | LTC1DAY | ONE DAY SUPPLY |
| 27 | LTC43DAY | FOUR THEN THREE DAY SUPPLY |
| 28 | LTC223DAY | TWO, THEN TWO, THEN THREE DAY SUPPLY |
| 29 | LTCDAILY3D | DAILY AND THREE-DAY WEEKEND (pharmacy or remote dispensed daily during the week and combines multiple days dispensing for weekends) |
| 30 | LTCSHIFT | PER SHIFT DISPENSING |
| 31 | LTCMED | PER MED PASS DISPENSING |
| 32 | LTCPRN | PRN ON DEMAND |
| 33 | LTC7ORLES | SEVEN DAYS OR LESS (cycle not otherwise represented) |
| 34 | LTC14DAY | FOURTEEN DAY DISPENSING |
| 35 | LTC814DAY | EIGHT TO FOURTEEN DAYS DISPENSING (cycle not otherwise represented) |
Abbreviations: "MT PLN LMT" - Meets Plan Limitations; "SHRTLOALTC" - Short-Fill Leave of Absence from LTC; "REMANAFTEK" - Remainder AFT Emergency Kit; "AFT" - After hours or indicates that the transaction is a replacement supply for doses previously dispensed to the patient after hours; "CMS" - Centers for Medicare and Medicaid Services.
Please note: Values "06", "14", "17" and "22" through "35" will have a prorated dispensing fee applied. Pharmacists may use SCC "10" and "21" for scenarios where drugs are dispensed in their original container, as indicated in the Food and Drug Administration (FDA) prescribing information, or those that are customarily dispensed in their original packaging to assist patients with compliance. The NYS Department of Health (DOH) will continue to monitor the use of these codes to ensure compliance. Medicine cabinet drugs and emergency kit replenishment are included in the LTC rate and may not be separately billed to NYS Medicaid.
Questions and Additional Information:
- Claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
- NYRx coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
- MMC reimbursement, billing, and/or documentation requirement questions should be directed to the MMC Plan(s) of the enrollee.
- MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers Managed Care Information document.
The Medicaid Update is a monthly publication of the New York State Department of Health.
Kathy Hochul
Governor
State of New York
James McDonald, M.D., M.P.H.
Acting Commissioner
New York State Department of Health
Amir Bassiri
Medicaid Director
Office of Health Insurance Programs
