Pharmacy Reject Codes for Medicaid Non-Enrollment

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Pharmacy Reject Codes for Medicaid Non-Enrollment

Beginning Sept. 1, 2022, EmblemHealth will deny claims from providers who are not enrolled with the New York State (NYS) Medicaid program either as an individual biller or ordering practitioner.

This means non-enrolled providers will not receive reimbursement for services rendered for EmblemHealth Medicaid and Health and Recovery Plan (HARP) members, and their prescriptions will be denied at the pharmacy.

Below is an explanation of the pharmacy National Council for Prescription Drug Programs (NCPDP) reject codes that pharmacies will receive:


NCPDP Reject 40 – Pharmacy Not Contracted with Plan on Date of Service

 

  • - Reject used for Geographic Restriction Network with message: “Fill Outside of Plan Area.”
  • Reject override only available for Geographic Restriction Network.
  • Secondary override message: “Pls call your plan for a mbr level PA.”


NCPDP Reject 890 – Non-Matched Pharmacy Number

  • Reject used for pharmacy Medicaid ID logic with message: “Pharmacy Medicaid ID not on file.”
  • Secondary override message: “Pls call your plan for a mbr level PA.”

NCPDP Reject AC – Product Not Covered Non-Participating Manufacturer

  • Reject used for CMS rebates.
  • Reject override only available for Medicaid CMS rebates exclusions.
  • Reject message for Medicaid CMS Rebate: “Requires national drug rebate agreement.”


NCPDP Reject 71 – Prescriber Is Not Covered

  • Reject override only available for client specific prescriber block lists.
  • Reject message for prescriber block list: “PRESCRB NOT CVD.”


NCPDP Reject 889 – Prescriber Medicaid ID Not Covered

  • Reject used for prescriber Medicaid ID logic with message: “Prescriber Medicaid ID not on file.”
  • Secondary override message: “Pls call your plan for a mbr level PA.”

As a reminder, federal and state laws require all Medicaid Managed Care (MMC) network furnishing (pharmacy), ordering, prescribing, referring, and/or attending (OPRA) providers to be enrolled with the NYS Medicaid fee-for-service program to continue servicing MMC members. Enrollment information is available at emedny.org/info/ProviderEnrollment/index.aspx.

For more information about the mandate, see the Jan. 2018 NYS Medicaid Update article titled "Medicaid Managed Care and Children´s Health Insurance Program Network Providers Must Enroll in the New York State Medicaid Program."

If you have any questions about reject codes, please sign in here and use EmblemHealth’s Message Center to send your inquiry. 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#59814 10/2022