Effective February 21, Change Healthcare started to experience network issues expected to continue throughout the weekend. To ensure Medicaid members receive necessary prescriptions and pharmacies have necessary guidance the agency offered the following:
- Claim Processing/Prescription and Emergency Fills: Claims are not processing currently. Existing federal law requires that a 72-hour emergency supply of a prescription drug be dispensed to Medicaid patients when the medication is needed without delay. Claims will be processed once the Change Healthcare system issues have been resolved. It is expected that providers will adhere to the provider agreements, which prohibit billing members when Medicaid will pay for services. Please refer to the provider manual for the limitations on billing members Vermont Medicaid Provider Manual (vtmedicaid.com).
- Eligibility: Eligibility must be verified through the automated Voice Response System (VRS), 800.925.1706, option 1 and then option 1 again or by utilizing online Transaction Services (https://vtmedicaid.com/#/home). For those members indicating new enrollment as of February 23, please call Maximus at 855-899-9600 during business hours and for afterhours please call the automated Voice Response System (VRS).
- Pharmacy Procedures: Many pharmacies have established internal procedures to handle such situations and we encourage dispensing medications to affected members to ensure continuity of care.
- Prior Authorizations: The outage is impacting the ability to issue prior authorizations. Therefore, prior authorization will be retroactively reviewed and applied for prescriptions filled during the system outage. Pharmacies must review the PDL to ensure the criteria is met prior to issuing new medications. Preferred Drug List (PDL) & Clinical Criteria | Department of Vermont Health Access
- Refills should be issued as requested based on the member’s history and clinical judgement. These claims will also be subject to a retroactive review.
- Controlled substance prescriptions: Please review the Vermont Prescription Monitoring System (VPMS) system as required.
- Helpdesk Access: Due to the outage, pharmacies are temporarily unable to contact the pharmacy helpdesk via phone or fax. Change Healthcare has indicated that the cause of the outage has been identified and they are working actively to restore normal operations. For questions, contact the Department of Vermont Health Access Pharmacy team at 802-879-5000 or ahs.dvhaph@vermont.gov.
For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.