SPECIAL BULLETIN COVID-19 #12: Suspension of Pharmacy POS Adult and Pediatric Behavioral Health Clinical Edits

The Outpatient Pharmacy point of sale (POS) adult and pediatric clinical edits for behavioral health medications will temporarily suspend effective March 23, 2020. These point of sale edits target dosages exceeding the FDA approved maximum limit and in class therapeutic duplication.  

Claims meeting the edit criteria deny and a message about the issue is returned to the pharmacy. After the pharmacist contacts the prescriber for clinical justification, the claim, resubmitted with the override submission clarification code (SCC) 10, pays. During the period of suspension, claims will not deny for the adult and pediatric behavioral health clinical edits and the pharmacy will not have to use override SCC 10 for the claim to pay.            

Pharmacy Clinical Policy also wants to remind medical and pharmacy providers that effective March 13, 2020, NC Medicaid extended the days supply allowed for most non-controlled substance outpatient prescription medications to 90 days. NC Medicaid strongly encourages medical providers to write, and pharmacies to fill, prescriptions for up to 90 days supply, where clinically appropriate.

GDIT, (800) 688-6696