UPDATE: This bulletin has been updated to include links to the flyer and the beneficiary next steps document (also linked in the final paragraph of this bulletin) that the NC Medicaid team published to help inform members of the next steps.
As Medicaid expansion launches on Dec. 1, 2023, NC Medicaid reminds providers that prescriptions written by non-Medicaid enrolled providers will not be reimbursable by NC Medicaid due to federal requirements. NC Medicaid requires that all providers whose NPI will be used on a pharmacy claim be enrolled with NC Medicaid. There are no exceptions to this requirement. This bulletin applies to NC Medicaid Direct and NC Managed Care.
NC Medicaid anticipates close to 300,000 new beneficiaries will receive full Medicaid coverage through Medicaid expansion on Dec. 1, 2023. Many of these beneficiaries may have had primary care services in free and charitable clinics who do not bill and are not enrolled in NC Medicaid.
- This means that beneficiaries with prescriptions from non-Medicaid enrolled individual providers will be denied coverage, and the beneficiary will not be able to fill their prescription through the NC Medicaid benefit.
- The pharmacy may fill the prescription at full cost for the beneficiary.
For clinics that dispense medications at no cost to patients, providers should consider dispensing an additional 30-day supply of medications to support the new Medicaid beneficiary during the transition period to allow time for beneficiaries to engage with their new NC Medicaid provider and/or time for non-Medicaid providers to enroll in NC Medicaid. Non-enrolled providers are encouraged to consider enrolling in NC Medicaid so prescriptions can be covered benefits.
To receive payment for office visits for Medicaid beneficiaries, a provider must fully enroll; however, there is a “lite” enrollment option that will allow providers to enroll as an Ordering, Prescribing, Referring (OPR) provider.
- The OPR provider enrollment process is a simpler and easier path to enroll into NC Medicaid only for the purposes of ordering, prescribing and/or referring beneficiaries for services.
- The estimated completion time for OPR provider enrollment is approximately one to two weeks from the application submission (if there are no issues with the submitted application).
- Enrolling as an OPR only provider would enable providers to prescribe medications, which are billed to NC Medicaid by the pharmacy, without the provider having to enroll as a full rendering Medicaid provider.
- If a provider would like to continue to serve NC Medicaid beneficiaries, providers must enroll as a full Medicaid provider.
Non-Medicaid enrolled providers treating beneficiaries who will enroll in NC Medicaid through Medicaid expansion should submit an OPR application as soon as possible. To enroll in NC Medicaid as an OPR only provider, providers can go to the NCTracks Provider Enrollment page.
- Under Quick Links, there is a user guide for “How to Enroll in NC Medicaid as an Individual Practitioner.”
- Select “Ordering, Prescribing, Referring Providers Enrolled with the Lite Application” (or if fully enrolling, select “Individual Full Enrollment”) as the Provider Enrollment Application Type.
- After submitting the application, applying providers should make sure to quickly respond to any notification regarding the application and reach out for assistance as soon as needed to ensure quick resolution of any open items impacting enrollment.
For more information on OPR provider enrollment, please review the OPR Provider FAQs.
When pharmacies process prescriptions for NC Medicaid beneficiaries that are denied due to the provider not being enrolled, pharmacists should encourage beneficiaries to schedule an appointment with their new NC Medicaid enrolled provider as soon as possible.
Beneficiaries should also be encouraged to seek out urgent care, Federally Qualified Health Centers (FQHCs) or the emergency department if they have an immediate need for medications to avoid gaps in care. Additionally, if the beneficiary received a prescription from a free clinic, the beneficiary should be encouraged to go back to the free clinic to refill their prescription until they are able to set-up an appointment with their NC Medicaid provider. Pharmacists are also encouraged to reach out to non-Medicaid enrolled providers regarding enrollment and to inquire if there is another NC Medicaid provider with an established relationship with the beneficiary who can write a new prescription for the beneficiary.
In summary, please see the below actions for prescribers and pharmacies:
- Actions for Prescribers: Non-Medicaid enrolled providers treating a beneficiary enrolling in NC Medicaid through Medicaid expansion should consider applying to enroll in NC Medicaid. No additional action is needed for actively participating providers.
- To receive payment for office visits for Medicaid beneficiaries, a provider must fully enroll in NC Medicaid.
- If the only intent is to ensure prescriptions are paid by Medicaid, non-enrolled providers may choose the lite enrollment option which only allows claim payment when the provider is ordering or referring for services, or prescribing medications. The lite provider enrollment process is a simpler and quicker way to enroll into NC Medicaid when the provider does not intend to bill for rendered services.
- Actions for Pharmacies: When pharmacies process prescriptions for NC Medicaid beneficiaries, which deny due to the provider not being enrolled, they should:
- Contact non-Medicaid enrolled providers regarding enrollment and to inquire if there is another NC Medicaid provider with an established relationship with the beneficiary who can write a new prescription for the beneficiary.
- Encourage beneficiaries to schedule an appointment with their new NC Medicaid enrolled provider as soon as possible.
- Encourage beneficiaries to seek out urgent care or the emergency department if they have an immediate need for medications or a medical emergency.
- Encourage beneficiaries to go back to the free clinic (if applicable) to refill their prescription until they are able to set-up an appointment with their NC Medicaid provider.
NC Medicaid has developed a flyer which can be posted at pharmacies which links to a next steps document to help beneficiaries resolve this issue.
Contact
NCTracks Call Center: 800-688-6696