NC Medicaid is receiving reports of pharmacists not utilizing the 72-hour Emergency Supply Override and the 01-No Other Coverage Identified code when applicable. Resistance to use these overrides is preventing Medicaid beneficiaries from being able to access necessary medications. As NC Medicaid providers, pharmacists are asked to please become familiar with these options and utilize them appropriately when administering the Medicaid benefit.
Pharmacists are asked to utilize the 72-Hour Emergency Supply Override when clinically appropriate for Medications pending Prior Authorization. For Medicaid members, including Medicaid Managed Care, Pharmacy providers are encouraged to use the 72-hour emergency supply allowed for drugs requiring prior approval. Federal law requires that this emergency supply be available to Medicaid beneficiaries for drugs requiring prior approval (Social Security Act, Section 1927, 42 U.S.C. 1396r-8(d)(5)(B)). Use of this emergency supply ensures access to medically necessary medications. With use of the override, the system will bypass the prior approval requirement, if an emergency supply is indicated. The pharmacist should use a “3” in the Level of Service field (418-DI) to indicate the transaction is an emergency fill. * Copayments apply to emergency fills and drug cost is reimbursed; however, a dispensing fee is not paid. There is no limit to the number of times the emergency supply can be used. *Codes may vary by managed care plan. This is the specific code for Medicaid Direct.
Pharmacists are asked to utilize the “01-No Other Coverage Identified” when a Medicaid claim rejects due to another payor on record. Medicaid is the payer of last resort, which means after any other insurance pays, Medicaid will pay. The other third-party payer must be billed as the primary payor when third party insurance exists, and then Medicaid can be billed as the secondary payor. When a claim is denied due to another payor on record being expired or terminated, the point-of-sale system will deny the claim, and the pharmacist will be prompted to submit the claim to another payer. In the event a beneficiary cannot produce another insurance or the beneficiary states they no longer have the other insurance, the pharmacy shall use the override code “01 – No Other Coverage Identified” in the Other Coverage Code claim segment 308-C8 for NCPDP D.0 transaction. * NC Medicaid will pay the pharmacy and seek payment from the third party, if appropriate. The pharmacy is not held liable for any payments made in these cases. *Codes may vary by managed care plan. This is the specific code for Medicaid Direct.
Thank you for your time and attention to this valuable information regarding the NC Medicaid Pharmacy Benefit. If you have any questions or concerns with the utilization of these override codes, please contact Angela Smith, Director NC Medicaid Pharmacy Benefit, or the Managed Care Plans directly.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.