Pharmacy Billing Guidance Exceptions for Non-Enrolled Prescribers

New York State (NYS) requires all licensed prescribers and pharmacies who serve Medicaid members to be enrolled with the Medicaid fee-for-service program. This includes prescribing practitioners identified on pharmacy claims per the Centers for Medicare & Medicaid Services (CMS) and federal regulations.

However, under the Medicaid Provider Enrollment Compendium there are two exceptions to the provider enrollment requirement:

1. Interns, residents, and foreign physicians in training.
   
   Pharmacies will receive the following NCPDP reject codes/place of service (POS) rejection messaging for prescriptions written by interns, residents, and foreign physicians in training:
   
   NCPDP Reject 889 – Prescriber Medicaid ID Not Covered
   1. Reject used for prescriber Medicaid ID logic with message: “Prescriber Medicaid ID not on file.”
   2. To submit an override request, contact EmblemHealth by signing into our Message Center at emblemhealth.com/providers. You can also call EmblemHealth at 888-447-7364 (TTY: 711). Our hours are 8 a.m. to 6 p.m., Monday through Friday, and 10 a.m. to 1 p.m., Saturday and Sunday.
2. Out-of-state (OOS) licensed prescribers that are treating Medicaid members for a single instance of emergency care within 180 days. These prescribers need to be either enrolled in Medicare with an “approved” status or enrolled in their own state’s Medicaid plan.Pharmacies will receive the following NCPDP reject codes/POS rejection messaging for prescriptions written by OOS licensed prescribers:
   
   NCPDP Reject 889 – Prescriber Medicaid ID Not Covered
   1. Reject used for prescriber Medicaid ID logic with message: “Prescriber Medicaid ID not on file.”
   2. To submit a one-time override request, contact EmblemHealth by signing into our Message Center at emblemhealth.com/providers. You can also call EmblemHealth at 888-447-7364 (TTY: 711). Our hours are 8 a.m. to 6 p.m., Monday through Friday, and 10 a.m. to 1 p.m., Saturday and Sunday.
   3. Please Note: Pharmacist should document the enrollment status of the OOS licensed prescriber in Medicare or Medicaid in their own state and the circumstance in which the claim qualifies for a single instance of emergency medical care as noted above. 

When requesting overrides according to the above policies, pharmacists should use their professional judgement, prescriber's information at hand, and available member history. Pharmacists should contact EmblemHealth directly for claims that do not meet the exceptions outlined above.
 

All questions regarding these policies can be sent to EmblemHealth by signing in to our Message Center. You can also call EmblemHealth at 888-447-7364 (TTY: 711). Our hours are 8 a.m. to 6 p.m., Monday through Friday, and 10 a.m. to 1 p.m., Saturday and Sunday. Pharmacies with questions regarding their credentialing status should contact Express Scripts at networkcompliance@express-scripts.com.

JP#60838 12/2022