The Department of Healthcare and Family Services (HFS) recently released 2023 Q4 and 2024 Q1 payments for the Critical Access Pharmacy (CAP) Program. Due to the Change Healthcare System outage earlier in the year, the Q4 data was not complete, and the Q1 data was estimated, and both will be reconciled as part of the 2024 Q2 payments once all the data from the Medicaid managed care plans has been submitted.

HFS made the estimated payments to ensure CAPs received these important funds. Please note that new pharmacies who have never received CAP funds had no estimated payment available for Q1, and therefore did not receive an initial CAP payment. HFS will also reconcile these pharmacy payments when the Q2 payments are processed.

If you have any questions, please contact a pharmacy billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.

Also in Illinois, the Department informed pharmacies that the 2024-2025 influenza vaccine National Drug Codes (NDCs) have been loaded to the Pharmacy Billing Management System (PBMS) and can now be billed.

To receive the vaccine administration fee, pharmacies billing the Medicaid fee-for-service (FFS) program should enter the administration fee amount in the Incentive Amount Submitted field (438-E3). If the value in this field exceeds $6.40, the maximum allowed by the Department of Healthcare and Family Services (HFS), the claim will only pay an administration fee of $6.40. If the value of the field is less than or equal to the HFS allowed amount, the system will pay the lesser of the two. The value ‘MA’ must be entered in the Professional Service Code field (440-E5) unless no administration fee is billed. The claim will reject if it is submitted with an incorrect value in one of these fields. If a claim is submitted with an NDC for an influenza vaccine, but neither of these fields is populated, no administration fee will be paid.

For managed care organization (MCO) claims, please contact the applicable MCO for billing instructions.

Questions should be directed to a billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.