DOH Provides Pharmacy Billing Guidance

An article in the June edition of the Medicaid Update urges nursing homes to be diligent in checking resident eligibility for other insurance coverage prior to submitting pharmacy claims to Medicaid. The Medicaid Update, available here, outlines the process homes need to follow before submitting pharmacy bills to Medicaid. It reminds providers that it is their responsibility (the facility as well as the pharmacy) to actively and regularly seek Third-Party Liability (TPL) coverage for their residents.

Homes should determine TPL using all available resources, including the facility’s billing office, the Medicaid Eligibility Verification System (MEVS) & TPL, and ePACES. If TPL is applicable, providers must bill the third-party insurer first, including commercial plans or Medicare, and bill Medicaid as secondary, if appropriate. Any claim issues must be resolved with the third-party insurer, including prior authorization requirements, prior to submitting the claim to Medicaid. If the primary insurer does not cover a specific medication, Medicaid will not cover the claim. Failure to submit the claim to the third-party insurer will result in denial of the claim by Medicaid.

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841