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Michigan Department of Community Health Medicaid program

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Welcome to the website for the Michigan Department of Community Health Medicaid program - Point of Sale System (POS).

Web Announcements

March 2014

** Notice ** Effective 04/01/2014 - Healthy Michigan Plan

Effective 4/1/2014, Michigan Department of Community Health will begin accepting applications for the Healthy Michigan Plan online, by phone, or in person at local Michigan Department of Human Services offices. For continuous information about the progress of the Healthy Michigan Plan or more details regarding enrollment, visit www.michigan.gov/healthymichiganplan

February 2014

Condoms - Prescription NOT required

This is a reminder that, in accordance with Medicaid Provider Manual (Pharmacy Chapter - Section 14.4.A. Condoms), the Michigan Department of Community Health does NOT require a prescription for condoms to be covered as a pharmacy benefit. A pharmacy may provide condoms at the beneficiary’s request. Both males and females are eligible to receive condoms. When billing condom claims a pharmacy can report its NPI (Type 2) in the Prescriber ID field along with the most appropriate Prescription Origin Code field (NCPDP field 419-DJ). The system is coded to allow these claims to continue processing even if the Prescription Origin Code field is left blank or the value zero (Not known) is reported. There are quantity and payment limitations (e.g. 12 condoms per fill, max 36 condoms per 30 days). Please contact the Technical Call Center at 1-877-624-5204 or MDCHPharmacyServices@michigan.gov mailbox with questions.

** Notice ** Effective 01/01/2014 - CAQH Requirements Compliance

As required by the Committee for Affordable Quality Healthcare (CAQH), Magellan Health Services will implement online enrollment for Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) effective January 1, 2014.

A help document that includes instructions and Frequently Asked Questions (FAQ) for ERA and EFT online enrollment can be accessed at pharmacy.magellanpharmacysolutions.com. Online ERA or EFT enrollment request can be accessed and submitted via the website at eftera.magellanmedicaid.com.

Paper ERA and EFT enrollment forms have been revised as required by the Committee for Affordable Quality Healthcare (CAQH). Instructions and Frequently Asked Questions (FAQ) for the new paper forms can by accessed at pharmacy.magellanpharmacysolutions.com.

Reminders:
ERA and EFT re-enrollment is not required. If you currently receive ERA or EFT you do not need to do anything.
Effective January 1, 2014 providers requesting new ERA or EFT enrollment, changes or cancelations can make these requests via the website or submit a paper form.
If you have additional questions, please contact the following:

General Contact at RxNetworksDept@magellanhealth.com
Fax to 1-888-656-4139

January 2014

Pharmacy EFT/Check Release Delay

Due to inclement weather causing State of Michigan offices and many banks to be closed Monday, January 6, 2014, this week's pharmacy provider payments will be delayed at least one business day.

December 2013

MIChild Health Plans to Cover Psychotropics

The MIChild contract previously excluded psychotropics except for ADD and ADHD drugs when prescribed by the Contractor’s provider network. However, to prevent and address reports of medication access challenges, the Michigan Department of Community Health (MDCH) will be amending the contract to include psychotropic drugs as part of the pharmacy benefits covered by the MIChild Plans moving forward. This will take a bit of time to implement, but in the interim, DCH sent notification on November 27, 2013 requesting all MIChild plans to immediately modify their pharmacy procedures to assure that these medications are approved when presented at pharmacies. Enrollees and/or pharmacy providers experiencing an issue should contact the MIChild Health Plan for assistance. A MIChild Health Plan Service Contact list is available on the Department’s website at: http://www.michigan.gov/mdch/0,4612,7-132-2943_4845_4931-312355--,00.html .

November 2013

SYSTEMS MAINTENANCE NOTICE

Magellan Medicaid Administration will be performing system maintenance during the regular scheduled maintenance window this Sunday beginning at 1am, Sunday, 11/24/2013. The outage is expected to last for four hours. Call center agents will not be able to log any calls or perform any lookups. Agents will not be able to create PAs during this time. They will manually capture PA requests which will be entered once the system has come back online.

Effective 01/01/2014 CAQH Requirements Compliance

This notice is informational and Magellan is not requesting anything of you at this time. This communication is intended to keep you informed of CMS requirements and our efforts to comply by the set forth effective date.

Magellan Health Services is presently seeking to comply with the new CMS (Centers for Medicare & Medicaid Services) requirements effective January 1, 2014 as communicated through the CAQH (Committee for Affordable Quality Healthcare) Phase III Core EFT and ERA Operating Rules section 1104. The required changes apply to entities that use, conduct, or process the v5010 835 transaction and EFT. Please visit CAQH Requirements Compliance for more detailed information.

October 2013

Pharmacies using MPHI Health Plan Benefits website

Effective immediately, any pharmacy that is not enrolled as a DME provider and who utilizes the Health Plan Benefits website, healthplanbenefits.mihealth.org must complete their enrollment in CHAMPS as a FACILITY/AGENCY/ORGANIZATION (FAO) provider type and associate MPHI as their Billing Agent in CHAMPS. For assistance with Michigan Department of Community Health CHAMPS pharmacy enrollment process please review the CHAMPS Pharmacy Provider Enrollment Notice for additional details and resources. Questions pertaining to pharmacy enrollment should be directed to the Department’s Provider Support Line at 1-800-292-2550, option 3.

NETWORK OUTAGE SCHEDULED FOR THIS WEEKEND:

Magellan Medicaid Administration will have a full system outage scheduled during our standard maintenance window this weekend to perform upgrades that are required to further support redundancy and ensure that we are operating with the most current technology.
Date/Time:
Sunday 10/13/2013, 2-3am ET (1-2am CT)

Effective 01/01/2014 CAQH Requirements Compliance Effective:

As required by the Committee for Affordable Quality Healthcare (CAQH), Magellan Medicaid Administration on behalf of the Michigan Department of Community Health is presently seeking to comply with new CAQH requirements as of January 1, 2014. The required changes apply to entities that use, conduct, or process the v5010 835 transaction. Please visit CAQH Requirements Compliance for more detailed information.

September 2013

Pharmacy Seasonal Flu Vaccine Administration 2013-2014

MDCH policy of covering the administration and ingredient cost of seasonal flu vaccines as a Fee-for-Service pharmacy benefit is still effective. The national drug codes for the 2013-2014 flu season will be coded to pay at point-of-sale no later than September 30, 2013 and reimbursement amounts will align with the Department fee screens when administered as a practitioner benefit – see table below for additional details. NOTE: Section 7.13.2 Seasonal Flu Vaccine within the D.0 Pharmacy Claims Processing Manual contains additional claim submission and coverage details (e.g. covered only for beneficiaries 19 and older, etc.). Below is a list of the products for the 2013-2014 Flu Season:

NDCLabel NameIngredient Cost AllowedAdmin Fee Allowed
33332001301AFLURIA 2013-2014 SYRINGE$ 12.40$ 7.00
33332001302AFLURIA 2013-2014 SYRINGE$ 12.40$ 7.00
33332011310AFLURIA 2013-2014 VIAL$ 11.37$ 7.00
58160088041FLUARIX 2013-2014 SYRINGE$ 12.40$ 7.00
58160088052FLUARIX 2013-2014 SYRINGE$ 12.40$ 7.00
58160090041FLUARIX QUAD 2013-2014 SYRINGE$ 12.40$ 7.00
58160090052FLUARIX QUAD 2013-2014 SYRINGE$ 12.40$ 7.00
19515089002FLULAVAL 2013-2014 VIAL$ 11.37$ 7.00
19515089007FLULAVAL 2013-2014 VIAL$ 11.37$ 7.00
66019030010FLUMIST NASAL 2013-14 VACCINE$ 23.46$ 3.00
66521011602FLUVIRIN 2013-2014 SYRINGE$ 12.40$ 7.00
66521011612FLUVIRIN 2013-2014 SYRINGE$ 12.40$ 7.00
66521011610FLUVIRIN 2013-2014 VIAL$ 11.37$ 7.00
49281001350FLUZONE 2013-2014 SYRINGE$ 12.40$ 7.00
49281001388FLUZONE 2013-2014 SYRINGE$ 12.40$ 7.00
49281039215FLUZONE 2013-2014 VIAL$ 11.37$ 7.00
49281039278FLUZONE 2013-2014 VIAL$ 11.37$ 7.00
49281001310FLUZONE 2013-2014 VIAL (PF)$ 12.40$ 7.00
49281001358FLUZONE 2013-2014 VIAL (PF)$ 12.40$ 7.00
49281039365FLUZONE HIGH-DOSE 2013-14 SYR$ 30.92$ 7.00
49281039388FLUZONE HIGH-DOSE 2013-14 SYR$ 30.92$ 7.00
49281070748FLUZONE INTRADER 2013-2014 SYR$ 18.98$ 7.00
49281070755FLUZONE INTRADER 2013-2014 SYR$ 18.98$ 7.00
49281011300FLUZONE PEDI 2013-2014 SYRINGE$ 12.40$ 7.00
49281011325FLUZONE PEDI 2013-2014 SYRINGE$ 12.40$ 7.00

August 2013

Notification of PDL Changes – effective September 17, 2013

A change scheduled for September 17, 2013 may affect one or more of your patients. Based on recommendations by the Michigan Department of Community Health’s Pharmacy & Therapeutics Committee (P&T), Michigan Medicaid will no longer have Ventolin® HFA (albuterol) inhaler or budesonide nebulizer solution (generic for Pulmicort Respules) as preferred agents on its Preferred Drug List (PDL). This change will be effective September 17, 2013. Notification letters have been sent to prescribers and beneficiaries that may be affected by the change.

Condoms - Prescription NOT required

This is a reminder that, in accordance with Medicaid Provider Manual (Pharmacy Chapter - Section 14.4.A. Condoms), the Michigan Department of Community Health does NOT require a prescription for condoms to be covered as a pharmacy benefit. A pharmacy may provide condoms at the beneficiary’s request. Both males and females are eligible to receive condoms. When billing condom claims a pharmacy can report its NPI (Type 2) in the Prescriber ID field and must either leave blank or report the value of zero (Not known) in the Prescription Origin Code field (NCPDP field 419-DJ). There are quantity and payment limitations (e.g. 12 condoms per fill, max 36 condoms per 30 days). Please contact the Technical Call Center at 1-877-624-5204 or MDCHPharmacyServices@michigan.gov mailbox with questions.

Electronic Funds Transfer and Electronic RA Agreement (EFT/835 Remittance Advice)

Effective immediately, any new pharmacy enrollments or updates to existing pharmacy enrollments must occur in the Michigan Department of Community Health’s CHAMPS system. However, Magellan Medicaid Administration will continue to manage the EFT and 835 Remittance Advice set-up. Magellan Medicaid Administration Provider Relations Department will contact the pharmacy provider (once MDCH has completed the enrollment process)to set up the funding process. This step must be completed prior to claim submission. Questions pertaining to EFT and/or 835 Remittance Advice should be directed to the Magellan Medicaid Provider Support Line at 1-888-868-9219.

July 2013

CHAMPS Pharmacy Provider Enrollment Transition

Effective immediately, any new pharmacy enrollments or updates to existing pharmacy enrollments must occur in the Michigan Department of Community Health’s CHAMPS system. Please review the CHAMPS Pharmacy Provider Enrollment Notice for additional details and resources. Questions pertaining to pharmacy enrollment should be directed to the Department’s Provider Support Line at 1-800-292-2550, option 3.

June 2013

MI Medicaid MAC Research Request

Reminder: MI Medicaid Pharmacy providers can request for a MAC price review. Pharmacy providers may submit a MAC Price Research Request form located online with a copy of the invoice listing the current acquisition cost for the product (s) in question to Magellan Medicaid Administration via fax (888-656-1951) or email (StateMACProgram@MagellanHealth.com). For additional information, please refer to the MAC Frequently Asked Questions document.

Medicare Part D E1 Enhancement…

At the request of industry, CMS has authorized Relay Health to implement an enhancement to the Medicare Part D E1 Transaction to facilitate Best Available Evidence when there is a discrepancy in the information received from the beneficiary and/or Part D plan. On May 23, 2013, Relay Health will begin returning additional information on the E1 Transaction by including the LIS/LICS level, (low income subsidy co-pay category), LIS/LICS effective and termination dates (if applicable), and the Medicare Plan Type, when a beneficiary match is successful.

Additional technical information can be found in the attached memo. Please validate that your pharmacy system can support the return of this information. If you have any questions concerning this communication, please send all inquiries to TBTSupport@relayhealth.com.

May 2013

ACA Endorsement Attestation – Checks/Warrants

If you receive paper checks instead of EFT payments, in accordance with ACA requirements outlined in 42 CFR § 455.19 Provider’s statement on check, the following statement will be printed on the back of your Magellan Medicaid Administration check above the claimant’s endorsement area: "I understand in endorsing or depositing this check that payment will be from Federal and State funds and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws."

April 2013

ePrescribing Friendly Reminder (effective September 26, 2008)

Michigan Medicaid’s eligibility, utilization and formulary information has been available for ePrescribing purposes since September 2008. Please see the original provider notice with additional information and visit our ePrescribing page for additional information (http://michigan.fhsc.com/Providers/ePrescribing.asp).

March 2013

Hemophilia Utilization Program management

As of 04/01/2013, Magellan Medicaid Administration will manage the Hemophilia Utilization Program on behalf of the Michigan Department of Community Health. All requests should be directed to the MMA contact information below. Please click here to access the updated Hemophilia Case review Form.

  • Clinical phone number: 1-877-864-9014
  • Faxes should be faxed to: 1-888-603-7696

February 2013

FDA Recommends Lower Doses of Zolpidem for Women

New data show that blood levels of zolpidem in some patients may be high enough the morning after use to impair activities that require alertness, including driving. Because use of lower doses of zolpidem will result in lower blood levels in the morning, the Food and Drug Administration (FDA) is requiring the manufacturers of Ambien®, Ambien® CR, Edluar®, and Zolpimist® to lower the recommended dose for women, from 10 mg to 5 mg for immediate-release products and from 12.5 mg to 6.25 mg for extended-release products. For men, health care professionals should consider lower zolpidem doses, but it is not required.

On February 2, 2013, First Data Bank (FDB) implemented a new gender edit for pharmacy point-of-sale (POS) claims that limits these higher doses of zolpidem to only male beneficiaries. Currently, an override must be obtained from the Magellan Medicaid Administration, Inc (MMA) call center for higher dose (i.e. 10 mg or 12.5 mg) claims for zolpidem for females. A system modification is being made to allow provider-level overrides for these edits. This modification will be implemented on Friday, February 8, 2013. The FDA press announcement that contains more information on their recommendation is available at www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm334798.htm

December 2012

Pharmacy EFT/Check Release Dates

Payments will be distributed one business day early (on Friday 12/21/2012) due to the Christmas holiday.

November 2012

Medicare Part D Coverage of Benzodiazepines and Barbiturates 01/01/2013

As of January 1, 2013, Medicare Part D plans will cover benzodiazepines and barbiturates (used in the treatment of epilepsy, cancer, or a chronic mental health disorder).

For Medicare eligible beneficiaries, Michigan Department of Community Health (MDCH) coverage of barbiturates will be limited to only those claims for treatment of conditions not covered by the Medicare Part D plan.

After receiving a rejection from the Medicare Part D plan, the following BARBITURATES will pay at POS when the COB claim reports:

  • NCPDP Field # 3Ø8-C8 - Other Coverage Code value ‘3’ [3 = Other Coverage Exists, This Claim Not Covered]
  • NCPDP Field # 34Ø-7C - Other Payer ID value ‘66666666’ [66666666 = Medicare – Enrolled in Medicare Part D]
  • NCPDP Field # 472-6E - Other Payer Reject Code values of:
    • MR - Product Not on Formulary; or
    • A5 - Not Covered Under Part D Law
  • BUTALBITAL/ASPIRIN/CAFFEINE
  • BUTALBITAL/ACETAMINOPHEN/CAFFEINE
  • BUTALBITAL/ACETAMINOPHEN
  • MEPHOBARBITAL
  • SEDATIVE BARBITURATE

All other claims will deny NCPDP 41 – Submit bill to other processor or primary payer with supplemental message “Bill plan XYZ” or “No COB allowed, Bill Medicare Part D”.

The Medicaid program is no longer covering benzodiazepines for dual eligible recipients.

The following BENZODIAZEPINES will deny for NCPDP 41 – Submit bill to other processor or primary payer at POS and return the PART D plan information to the provider for claim submission: If the claim is billed with the COB segment, the claim will deny NCPDP 13- M/I Other coverage code.

  • ALPRAZOLAM
  • CHLORDIAZEPOXIDE
  • CHLORDIAZEPOXIDE HCL
  • CLORAZEPATE DIPOTASSIUM
  • DIAZEPAM
  • HALAZEPAM
  • LORAZEPAM
  • OXAZEPAM
  • PRAZEPAM
  • ESTAZOLAM
  • MIDAZOLAM HCL
  • QUAZEPAM
  • TEMAZEPAM
  • TRIAZOLAM
  • CLONAZEPAM
  • FLURAZEPAM HCL
Michigan Medicaid 835 Remittance Advice

As of 11/22/2012, MMA's internal process to create the unique reference number (ICN), will change to a more efficient process. The new internal process will not impact the provider's current use of the reference number, the value count or format.

Pharmacy EFT/Check Release Dates

Paper checks will be delayed one business day (i.e. on Tuesday) following Thanksgiving. EFT payments will be released as normally scheduled.

October 2012

XEROX ACS Pharmacy Audits

Please visit the Xerox ACS provider portal for MDCH pharmacy providers at www.michiganmedicaidrxaudit.com for important audit information. This provider portal is being enhanced and will soon identify the top post payment audit discrepancies. The portal also offers pharmacy providers ability to login securely to review information pertaining to their individual audits. MDCH post payment audits questions can be directed to:

  • Xerox Audit & Compliance Solutions
  • 700 Packer Avenue Suite 101
  • Philadelphia, PA 19148
  •  
  • Toll free: 1-800-742-7638
  • Direct: 1-215-551-3838
  • Fax: 1-888-772-1632

CMS Webinar – Payment Error Rate Measurement (PERM)

CMS will be conducting the next round of Payment Error Rate Measurement (PERM) audits beginning early November. Pharmacy providers are encouraged to participate in the CMS webinar on October 24, 2012 (see additional details below). If you have any questions regarding the PERM review please contact MDCHPharmacyServices@michigan.gov or (517) 241-8055. Click here for more information about PERM Audits.

  • Wednesday October 24, 2012
  • 2:00 – 3:00 PM EST
  • Toll free Dial-In #: (877) 251-0301
  • Phone Conference ID: 72421618
  • To join on-line meeting:
  • webinar.cms.hhs.gov/perm1web6/

COB Claim Submission

When submitting a COB claim, please populate both the Patient Responsibility Amount Qualifier ( Field 351-NP) and Patient Responsibility Amount fields (352-NQ and 353-NR) for each payer when the patient has more than one primary insurance and the Other Coverage Code (OCC) = 2.

Claims that do not have all appropriate fields populated will deny for one of the following of the NCPDP Error Codes:

  • NCPDP 536 - OP Pat responsibility Amt Qlfr Value not supported
  • NCPDP NP - M/I Other Payer Patient Responsibility Amt Qualifier
  • NCPDP NQ- M/I Other Payer Patient Responsibility Amount
  • NCPDP NR - M/I Other Payer Patient Responsibility Amount Count

September 2012

Psychotropic Prescribers CE Opportunity - EnhanceMed

Hurry space is limited!

The Michigan Department of Community Health’s Medicaid program encourages psychotropic prescribers RSVP right away before they miss this CE opportunity on its new Academic Detailing Initiative (EnhanceMed) targeting Behavioral Health/Psychotropic Prescribing. For additional details and RSVP contact information, please review the Provider Forum Series flyer.
EnhanceMed Provider Forum Series:

  • Monday, September 17, 2012: McCormick & Schmick’s Seafood Restaurant, Troy (6:00 p.m. – 8:00 p.m.)
  • Tuesday, September 18, 2012 –Troppo, Lansing (6:00 p.m. – 8:00 p.m.) - to be rescheduled
  • Wednesday, September 19, 2012: Mangiamo!, Grand Rapids (6:00 p.m. – 8:00 p.m.) - to be rescheduled

Independent Pharmacy Claim Reprocessing Update

Claims that were reprocessed in August and failed to pay at the higher reimbursement are currently being reviewed and providers will be contacted for an update.

Health Plan Carve-Out Additions

Effective October 1, 2012, in accordance with MDCH policy bulletin MSA 12-46, drugs used to treat coagulopathies such as hemophilia and orphan drugs used to treat rare metabolic conditions are excluded from the Medicaid Health Plan contract. Beginning October 1, 2012, drugs within the Michigan Pharmaceutical Product List (MPPL) drug classes identified below will be added to the Health Plan carve-out list and billed as a Fee-for-Service benefit to the Department’s PBM vendor (i.e. Magellan Medicaid Administration Inc.). Review the MPPL for additional drug product details.

   

CSHCS/MA beneficiaries enrolling in Medicaid Health Plans

As required by Section 1204 of Public Act 63 of 2011, effective October 1, 2012, Medicaid beneficiaries who have full Medicaid benefits and are also eligible for CSHCS coverage (hereafter referred to as CSHCS/MA) will transition from an excluded population to a mandatory population for purposes of Medicaid Health Plan (MHP) enrollment. The MHP enrollment process begins October 1, 2012. For additional details please review the MSA 12-46 policy bulletin.

August 2012

Pharmacy Seasonal Flu Vaccine Administration 2012-2013

MDCH policy of covering the administration and ingredient cost of seasonal flu vaccines as a Fee-for-Service pharmacy benefit is still effective. The national drug codes for the 2012-2013 flu season will be coded to pay at point-of-sale no later than August 31, 2012 and reimbursement amounts will align with the Department fee screens when administered as a practitioner benefit – see table below for additional details. NOTE: Section 7.13.2 Seasonal Flu Vaccine within the D.0 Pharmacy Claims Processing Manual contains additional claim submission and coverage details (e.g. covered only for beneficiaries 19 and older, etc.). Below is a list of the products for the 2012-2013 Flu Season:

   

Claim Reprocessing Delay

Independent pharmacy providers who received a notice informing them of an adjudication error, claim reprocessing has been delayed until the week of August 13 impacting the August 16, 2012 and August 23, 2012 check write.

April 2012

Michigan Department of Community Health's D.0 COB Reference Guide

Please click here for D.0 COB Reference Guide.

January 2012

Michigan Department of Community Health's Carrier ID Listing

Please click here for the list of MI Carrier IDs.

Pharmacy Liaison -2012 Quarterly Pharmacy Liaison Meetings
  • March 15 (Conf room F)
  • June 14 (Conf room E & F)
  • Sept 6 (Conf room E & F)
  • Dec 13 (Conf room E & F)
Acceptable Reject Codes updated for NCPDP vD.0

Several NCPDP reject codes new to new vD.0 have now been added to the list of Other Coverage Code (OCC) 3 Acceptable Reject c=Codes allowed for. Click here for a comprehensive list of codes allowed to process when submitted on COB claims with OCC 3 indicating the primary payer(s) were billed but the claim was not covered.

December 2011

NCPDP D.0 Reminder

Effective January 1, 2012, the Michigan Department of Community Health (MDCH) will be adopting the HIPAA 5010/NCPDP D.0 standards for all electronic healthcare transactions. MDCH encourages pharmacies to submit Point-of-Sale (POS) claims in D.0 format no later than 1/1/2012. If you are unable to submit D.0 claims on 1/1/2012, paper claims may be utilized until your software is HIPAA compliant.

CHAMPS System Outage notice

Effective January 1, 2012, the Michigan Department of Community Health (MDCH) will be adopting the HIPAA 5010/NCPDP D.0 standards for all electronic healthcare transactions. Due to this implementation, the Community Health Automated Medicaid Processing System (CHAMPS) will be experiencing a complete system outage beginning at 7:00 P.M. on Thursday, December 29, 2011 and will continue until Tuesday, January 3, 2012. During this four-day outage, CHAMPS access will not be available for any services it provides to users. The CHAMPS outage will not impact the availability of the Point-of-Sale (POS) pharmacy operated by the Department’s Pharmacy Benefit Manager, Magellan Medicaid Administration, Inc. Please see notification attached.

Pharmacy Liaison - Meeting Cancellation Notice - December 08, 2011

Please note that the quarterly Pharmacy Liaison Meeting scheduled for Thursday, December 8, 2011, at Capitol Commons Center has been cancelled. Meeting for the next quarter will be held on March 15, 2012.

If you have questions, feel free to contact Raji Dnyate at 517-241-9170 or e-mail dnyater@michigan.gov.

Thank you.

November 2011

Pharmacy EFT/Check Release Dates - Upcoming Holidays

Paper checks will be mailed the Tuesday following Thanksgiving, Christmas and New Years, instead of Monday. EFT payments will be delayed one business day (i.e. on Tuesday) following Christmas and New Years but will occur as usual on the Monday following Thanksgiving.

October 2011

NCPDP vD.0 Transition Date of Service Contingency

Magellan Medicaid Administration is pleased to accept NCPDP vD.0 claims prior to the mandatory submission beginning 1/1/2012. However, please note that during this dual processing period (10/3/2011-12/31/2011) claims submitted in vD.0 must have a Date of Service (NCPDP Field# 4Ø1-D1) on or after 10/3/2011. If you are submitting a NCPDP D.0 claim and receiving a rejection, please check the Date of Service on the submitted claim to ensure the Date of Service is on or after 10/3/2011. If needed, please call the Magellan Help Desk at 1-877-624-5204 for additional assistance.

AWP Pricing

The Department is reviewing claims that may have priced based on expired AWP pricing data in lieu of current WAC markup or MAC. Once the review is finalized, claims impacted have been identified and a provider mailing is scheduled for the week of 11/07/2011 to allow for claim reprocessing for potentially higher reimbursement based on the WAC markup or MAC. Please direct related questions to the contact number identified on your provider letter.

NCPDP D.0 Update (October 2011)

After additional testing and review, the Michigan Department of Community Health has updated its Appendix A of the Claims Processing Manual for Payer Specifications and Claims Processing Manual to reflect that Medicaid ID Number (115-N5) and Medicaid Indicator (36Ø-2B) are Optional. Earlier versions indicated these would be required fields. The NCPDP vD.0 Quick Reference was also updated.

Clotting Factors

Clotting factors MAC pricing is not currently included in web Drug Lookup. The most recent MAC pricing updates are located Clotting Factor MAC Pricing.

September 2011

Pharmacy Seasonal Flu Vaccine Administration 2011-2012

MDCH policy of covering the administration and ingredient cost of seasonal flu vaccines as a Fee-for-Service pharmacy benefit is still effective. The national drug codes for the 2011-2012 flu season will soon be coded to pay at point-of-sale and allowed reimbursement amounts will align with the Department fee screens when administered as a practitioner benefit.

Discontinuing Average Wholesale Price (AWP)

Effective for dates of service on or after December 1, 2010, the Michigan Department of Community Health (MDCH) added the Wholesale Acquisition Cost (WAC) markup equivalent of the current Average Wholesale Price (AWP) discount to its 'Lower of' pricing logic for pharmacy claims. MDCH implemented this budget-neutral policy change as a result of First Data Bank's intent to cease publishing Average Wholesale Price (AWP) data by September 2011. The WAC plus markup is identified below:

Pharmacy Group AWP Discount or WAC Markup
Pharmacies with 1-4 stores AWP minus 13.5% or WAC plus 3.80%
Pharmacies with 5 or more stores AWP minus 15.1% or WAC plus 1.88%
Pharmacies who serve beneficiaries with a level of care (LOC) 02 AWP minus 15.1% or WAC plus 1.88%

August 2011

Pharmacy EFT/Checks Release Date - Monday 08/22/2011

Checks were released on Tuesday 08/23/2011, instead of the regular scheduled Monday; therefore checks may be delayed by one business day. EFT's were released as scheduled on Monday 08/22/2011

Refilling a prescription when your pharmacy is no longer in business

If your pharmacy is no longer open or in business and it's time for you to refill one of your prescription medicines you can: 1) Take your prescription bottle to a new pharmacy or 2) Contact your doctor and request a new prescription be called or faxed to your new pharmacy. If you take your prescription bottle to a new pharmacy, the pharmacy will need to verify the original prescription. Please note that if the doctor who wrote your original prescription is no longer open or in business to verify the original prescription, you'll need to make an appointment with a new doctor to get a new prescription. Disclaimer: Existing coverage and billing limitations still apply.

July 2011

Transitioning to NCPDP D.0

In preparation of the transition from the NCPDP 5.1 to NCPDP D.0 format, an updated Pharmacy Claims Processing Manual including Payer Specifications is available for download. Magellan Medicaid Administration, Inc. is currently coordinating testing efforts with pharmacy software vendors in anticipation of allowing interested pharmacy providers to begin submitting the NCPDP D.0 claim format at Point-Of-Sale this fall. Please contact Dorothea Roane, 804.217.7900 or DMRoane@magellanhealth.com if you are interested in engaging in the testing efforts. As we've been indicating at the March and June 2011 pharmacy provider liaison meetings, MDCH is planning for dual processing this fall (i.e. accepting vD.0 as early as October but not requiring until 01/01/2012). The Department will also be including some basic information regarding this in an upcoming proposed policy bulletin.

To view July 2011 MPPL & PDL changes click here.

June 2011

Web Provider Enrollment Application

Beginning 05/20/2011, a new web-based provider enrollment application became publicly available on the website to streamline the provider enrollment process. You'll find the Web Provider Enrollment on the website at http://michigan.fhsc.com then clicking on the Providers tab. A helpful user guide for this new tool can be found within the Providers tab then selecting on the link to Manuals or from the link to References in the upper right corner of this home page

To view April 2011 MPPL & PDL changes click here.

March 2011

CHAMPS Contact Information Change

CHAMPS Provider Helpline and E-Mail Address The CHAMPS Provider Helpline number (1-888-643-2408) and the CHAMPS e-mail address (CHAMPS@michigan.gov) will be disabled effective March 30, 2011. Providers should direct all CHAMPS and Medicaid-related questions to the Medicaid Provider Inquiry Helpline at 1-800-292- 2550 or to the Provider Support e-mail address at providersupport@michigan.gov. In addition, the CHAMPS website located at www.michigan.gov/medicaidproviders >> CHAMPS is updated frequently. Providers should reference this website for CHAMPS information.

February 2011

System Maintenance Announcement

Magellan Medicaid Administration, Inc. will be performing scheduled system maintenance during the month of March. The scheduled downtime will begin Saturday, March 26th, at 5 p.m. ET and will remain down for approximately 6 hours. POS claim processing for the Michigan Department of Community Health will not be affected, however please note that the Magellan web applications (Web PA, Web RA, Drug Lookup, UAC) as well as First Decision and First IQ will be unavailable to authorized users during this maintenance window.

January 2011

Transitioning to NCPDP D.0

In preparation of the transition from the NCPDP 5.1 to NCPDP D.0 format, an updated Pharmacy Claims Processing Manual including Payer Specifications will be available for download in the next few months. Once the new claim submission requirements are finalized, Magellan Medicaid Administration, Inc. (on the Michigan Department of Community Health's behalf) will begin coordinated testing efforts with pharmacy software vendors in anticipation of allowing interested pharmacy providers to begin submitting the NCPDP D.0 claim format at Point-Of-Sale this fall (as early as October 2011). Check back to the website often for additional details.

Pharmacy EFT/Checks Release Date - Tuesday, 01/18/2011

Several banks will be closed this coming Monday 01/17/2011 in observance of Martin Luther King Jr. Day. Pharmacy Provider payments will therefore be released on Tuesday 01/18/2011.

New Toll-Free MAC Pricing Fax Number

Effective 01/03/2011: The new MAC pricing fax number is 1-888-656-1951. The Michigan MAC Pricing Request Form has been updated with this new toll-free number

November 2010

FDA Drug Safety Communication: FDA recommends against the continued use of propoxyphene

On 11/19/2010, the U.S. Food and Drug Administration (FDA) announced their recommendation against continued prescribing and use of the pain reliever propoxyphene because new data show that the drug can cause serious toxicity to the heart, even when used at therapeutic doses. FDA has requested that companies voluntarily withdraw propoxyphene from the United States market. Please visit the FDA website at http://www.fda.gov/Drugs/DrugSafety/ucm234338.htm for more details.

New Fax Form for Adult ADHD

A new PA request fax form is now available on the website for Adult ADHD therapy for ages over 17 years. This new form can be found within the Providers tab then by selecting the link to Forms. The purpose of the new form is to identify the necessary information that must be provided by the prescriber when requesting a prior authorization for Adult ADHD drug therapy. Please be sure to fully complete the fax form as incomplete forms will be denied.

September 2010

Reminder: NCPDP 20.9 Scenario

Effective for dates of service on or after October 1, 2010, claims submitted with Other Coverage Code 2 must now begin reporting the primary insurance co-pay responsibility in the Patient Paid Amount Submitted field (NCPDP field 433-DX). Please refer to the Department's Policy Bulletin MSA 10-13 for additional details.

Billing Instructions:

When submitting OCC (NCPDP field # 308-C8) with a value equal to “2” in the Claim Segment for a COB claim when the primary insurer made a payment, report the following information:

  1. Report the amount of any beneficiary liability (co-payment, co-insurance, and or deductible) in the Patient Paid Amount Submitted field (NCPDP field 433-DX) in the Pricing Segment.
  2. Report a zero dollar ($0.00) amount if there is no beneficiary liability under the primary insurer in the Patient Paid Amount Submitted field (NCPDP field 433-DX) in the Pricing Segment.
  3. If the Patient Paid Amount Submitted field is not populated, the claim will reject with NCPDP reject code DX – Missing/Invalid Patient Paid Amount Submitted. An override will not be granted.
  4. Report the amount paid by primary insurer in the Other Payer Amount Paid field (NCPDP field 431-DV).

Refer to the Pharmacy Claims Processing Manual for Michigan Department of Community Health for additional information on reporting COB claims. The Manual is available online at http://michigan.fhsc.com.

Reminder: Medicaid Health Plan Carve-out PA Grandfathering to end 09/30/2010

As outlined in the Michigan Department of Community Health's MSA-10-08 Policy Bulletin, products that were previously part of the 60/40 carve-out but became carved-out 100% at Point-of-Sale effective 04/01/2010. To facilitate a smooth transition, edits were implemented to 'grandfather' coverage and bypass PA requirements 04/01/2010 to 09/30/2010. Effective 10/01/2010, these products will be subject to current FFS pharmacy policies and coverage limitations, including prior authorization requirements.

Seasonal Flu Vaccine Administration

Effective 09/01/2010, the Michigan Department of Community Health will allow pharmacists to administer seasonal flu vaccines. Policy Bulletin MSA 10-30 contains additional details. Please note: claims submitted with the pharmacy's NPI as the Prescriber ID will reject with NCPDP 25 - M/I Prescriber ID. As outlined in the policy bulletin, Section 9204 of the Michigan Public Health Code, MCL 333.9204, authorizes health professionals other than physicians to administer an immunizing agent as long as the agent is being administered under the direction of a physician. Standing orders are required from a Michigan-licensed physician who is responsible for the clinical practice of the vaccine operations. The physician's NPI must be reported as the Prescriber ID (411-DB).

August 2010

MAC Look Up at NDC Level

Beginning 08/10/2010, a hyperlink to the web drug look up formulary tool has been added to the Maximum Allowed Cost (MAC) tab. The hyperlink will allow providers to access the web-based drug lookup tool to obtain MAC pricing information at the national drug code (NDC) level. There is a helpful user guide in the upper right corner of the main page within the web drug look up tool and the user guide can also be found within the Providers tab then selecting on the link to Manuals.

July 2010

Web Drug Formulary Lookup

Beginning 07/12/2010, a new web-based drug lookup tool will be publicly available on the website to assist providers, beneficiaries, pharmaceutical manufacturers and other end-users in researching various Michigan Department of Community Health drug coverage parameters. The look-up tool contains information at the national drug code (NDC) level, including whether the NDC requires Prior Authorization (PA), has a Maximum Allowed Cost (MAC), etc. You'll find the Web Drug Formulary Lookup on the website at http://michigan.fhsc.com then clicking on the Providers tab. A helpful user guide for this new tool can be found within the Providers tab then selecting on the link to Manuals.

MDCH Pharmacy Wholesaler Survey

The Michigan Department of Community Health (MDCH) is encouraging the participation of enrolled pharmacy providers in a wholesaler survey. The purpose of this survey is to collect information on the wholesalers you utilize and various purchasing provisions that may apply. The surveys can be completed anonymously. The Department will review the survey results to further evaluate current MAC pricing resources and processes. Click here to download the survey and THANK YOU for your participation!

June 2010

Important Information about Takeda Pharmaceutical Products and Michigan Medicaid

Click here to read the notice concerning Takeda Pharmaceuticals.

New Web RA Enrollment Process

MDCH is offering providers participating in the Michigan Medicaid programs the capability to eliminate paper remittance advices by registering to download their RA using Medicare Remit Easy Print (MREP). Providers currently receiving paper R/A’s could choose to retrieve their remittance advice from the MI website once they have registered through UAC. Registration will enable providers to obtain a PIN which they will use to gain access to their RA. There is no cost to participate in this feature. Click here to proceed to UAC registration.

May 2010

New Claim Processing Edits

To enforce existing Michigan Department of Community Health policy and payer specifications, two claim submission edits are being deployed:

  • First Name Validation: Effective 05/12/2010, claims will deny with NCPCP Error Code CA - M/I Patient First Name when the first two characters of the submitted Patient First Name (NCPDP Field# 310-CA) do not match the Department of Community Health's eligibility record.
  • Relationship Code Submission: Effective 06/10/2010, claims will deny for NCPDP Error Code 11- M/I Patient Relationship Code when any value other than 1 (Cardholder) is submitted in Relationship Code (NCPDP Field #306-C6).

Eligibility Verification Tools

The Michigan First Health Call Center has been experiencing an unusual volume of eligibility verification inquiries which has resulted in longer than expected wait times. The Department of Community Health encourages providers to use MPHI's free web-based eligibility verification system called the MI Healthplan Benefits Website and/or their HIPAA X12 270/271 Transaction (Real time & Batch).

For more information:

Providers without Internet Access may use the following options:

  • Contact the CHAMPS HelpLine at 888-643-2408
  • Out-Of-State Providers - Email: CHAMPS@michigan.gov or Phone: 517-708-4901

To view April 2010 MPPL & PDL changes click here.

April 2010

Mail Order Co-pay Reimbursement Claim Form Address Change

Effective April 1, 2010, all mail order co-pay reimbursement claim forms should be mailed to:
Paper Claims Processing Unit
Post Office Box 85042
Richmond, VA 23261-5042

March 2010

Changes to website on April 1, 2010:

The following items have new homes on this website:

  • Pharmacy Liaison meeting items have their own area under the Committees tab
  • Dose Optimization, Li Net notice, The Clinical Alert and all items from the Pharmacy tab are now located under the Providers tab
  • A new tab has been added for Beneficiaries
  • MAC pricing information is on new tab.
Medicaid Health Plan Carve-Out Changes

Medicaid Health Plan Carve-Out Changes Effective for service dates on or after April 1, 2010, the Therapeutic Drug Classes commonly known as the Medicaid Health Plan (MHP) 60/40 carve-outs will no longer be covered as part of the MHP benefit. Medications within these drug classes will be added to the existing MHP 100% carve-out and billed at point-of-sale (POS) directly to the Michigan Department of Community Health's (MDCH) contracted Pharmacy Benefit Manager (PBM). Click here to view carve out drug list. For additional details, please refer to the new Medicaid Health Plan 100% Carve-out list that will be effective 04/01/2010, the MSA Bulletin 10-08 for providers, and the Beneficiary Letter 10-02 that was mailed to MHP member households that may be impacted by this change. If you have any billing questions, please contact the FHSC Technical Call Center at (877) 624-5204.

January 2010

Plan First! Pharmacy Coverage

Plan First! is a family planning waiver program. This program covers low income women who do not qualify for Medicaid. A woman with insurance that does not cover family planning may qualify for Plan First!. Plan First! covers services related to family planning including a yearly pap and pelvic exam, office visits for family planning, and contraceptives. Plan First! beneficiaries may see any Medicaid enrolled physician or clinic they choose. Although Plan First! is a separate program and does not offer the same coverage as Medicaid, a miHealth card is issued to Plan First! beneficiaries and they would present a miHealth card to their pharmacy provider as their prescription insurance card. For additional details regarding Plan First! covered services, including pharmaceuticals, please refer to the Family Planning Waiver Codes - Plan First! that can be viewed at: www.michigan.gov/medicaidproviders under Billing and Reimbursement>>Provider Specific Information>>Family Planning.

December 2009

Dispensing Fee Change

Effective December 1, 2009, the Michigan Department of Community Health increased the standard pharmacy provider dispensing fees by $0.25. For additional information, please refer to the MSA 09-58 Provider Bulletin. Click here to view bulletin.

To view October 2009 MPPL & PDL changes click here.

October 2009

Reimbursement for Administration of H1N1 Vaccines by Pharmacies

Effective September 30, 2009, in an effort to improve access to the 2009 Influenza A (H1N1) monovalent vaccine, the Michigan Department of Community Health (MDCH) will begin reimbursing eligible pharmacies to administer this vaccine to Medicaid, ABW, MOMS, and CSHCS beneficiaries. View additional details in the MSA Bulletin 09-52. If you have any billing questions, please contact the FHSC Technical Call Center at (877) 624-5204.

September 2009

Automated Voice Response System

Emdeon informed the Michigan Department of Community Health that the Automated Voice Response System (AVRS) at 888-696-3510 will be decommissioned effective Tuesday, September 29th. Providers without internet access needed to utilize one of the web-based eligibility verification systems can still contact the CHAMPS HelpLine at 888-643-2408.

Provider Eligibility Verification Assistance

Michigan Department of Community Health providers should contact the CHAMPS Helpline at 888-643-2408 with questions about verifying eligibility through the MI Healthplan Benefits (MPHI), Emdeon, Netwerkes, web-DENIS or CHAMPS web-based systems. Click here for instructions on how to update your pharmacy access profile should you experience any difficulties with MI Healthplan Benefits (MPHI) web-based eligibility verification. Click here to view bulletin on Pharmacy Beneficiary Eligibility Verification

July 2009

Pharmacy NPI

Beginning 07/29/2009, a claim submitted with a pharmacy's NPI as the Prescriber ID will reject as NCPDP 25 - Missing/Invalid Prescriber ID.

Note: For condom claims, MDCH will continue to allow the submission of the pharmacy's NPI in the Prescriber ID field. Condom claims will not reject in this instance.

June 2009

Dispensing Fees

Effective July 1, 2009, the Michigan Department of Community Health is required to reduce the pharmacy provider dispensing fees back to the rates in effect prior to the April 1, 2009 increases. For additional information about this change and other Medicaid reductions resulting from Executive Order 2009-22, please refer to the MSA-09-28 Provider Bulletin. Click here to view bulletin.

March 2009

Co-pay Level Changes

The Michigan Department of Community Health (MDCH) received notification of upcoming drug database updates that will change the co-pay levels of select products for our program beneficiaries. The B 09-02 letter was sent to beneficiaries that may be affected by an increase in certain medicine co-pays.

To view April 2009 MPPL & PDL changes click here.

February 2009

Pharmacy Eligibility Verification Alternative

The Michigan Department of Community Health (MDCH) recently issued Policy Bulletin MSA 09-04 announcing the elimination of the free phone Automated Voice Response System (AVRS) to verify beneficiary eligibility as a result of Executive Order 2008-21. MDCH providers, including pharmacies, were directed to a free alternative using web-DENIS. MDCH has now been informed that some pharmacies (i.e. those not also enrolled as DME/Medical Suppliers with MDCH) may experience difficulty being granted web-DENIS access due to Blue Cross internal policies/procedures. We sincerely apologize for the inconvenience. In lieu of web-DENIS the MDCH has made arrangements for another free web-based alternative for pharmacy providers through the Michigan Public Health Institute (MPHI). Please click here for additional details. Your National Provider ID (NPI) must be submitted on the access form.

November 2008

Pharmacy Provider Re-Enrollment Process

All pharmacy providers who serve beneficiaries of MDCH must re-enroll by March 01, 2009 in order to avoid delays in claim processing.

A Pharmacy Re-Enrollment Profile Application (MSA-1626-R) containing the current information on your Trading Partner Agreement will be mailed to you on 12/01/08. Please review and make any needed changes to the Pharmacy Re-Enrollment Profile Application (MSA-1626-R) as well as complete any blank fields, sign and return to FHSC by 02/02/09. A confirmation fax will be sent once the updated Pharmacy Provider Revalidation Profile Application (MSA-1626-R) has been successfully processed. Please call FHSC Provider Enrollment Unit at 804-965-7619 or 804-965-7748 with any questions.

May 2008

NPI Cut over

Effective May 23, 2008, the Michigan Department of Community Health will only accept the NPI numbers for the Service Provider and the Prescriber ID. This requirement applies to all Michigan Governors Program (MiRx Prescription Drug Discount Card) claims submitted to First Health. When submitting claims using the NPI, Pharmacy Services providers are reminded to use the Service Provider ID qualifier of '01' in NCPDP field number 202-B2 and the Prescriber ID qualifier of “01” in the NCPDP field number 466-EZ. Claims that are not submitted with the service provider NPI will deny for NCPCP 05- M/I Pharmacy Number. And claims that are not submitted with the prescriber NPI will deny for NCPDP 25- M/I Prescriber ID.

FIELD NAME OF FIELD VALUE
2Ø1-B1 Service Provider ID 10 Digit NPI number (Pharmacy)
2Ø2-B2 Service Provider ID Qualifier Ø1 = National Provider ID (NPI)
411-DB Prescriber ID 10 Digit NPI number (Prescriber)
466-EZ Prescriber ID Qualifier Ø1 = National Provider ID (NPI)

April 2008

Unit of Measure Requirement

Effective 05/01/2008, MDCH will require the submission of the Unit of Measure (NCPDP Field 6ØØ-28). Claims without the Unit of Measure will reject with NCPDP 26 - Missing/Invalid Unit of Measure. In addition, the submitted Unit of Measure must match the national drug code's Drug Form reported by First Databank otherwise the claim will reject with NCPDP PZ - Non-matched Unit of Measure. Click here for the MSA 08-05 Policy Bulletin regarding this new requirement.

March 2008

Tamper Resistant Prescription Pads

Effective 04/01/2008, Michigan Medicaid is mandated to require tamper resistant prescription pads in accordance with the federal law, U.S. Troop Readiness, Veteran's Care, Katrina Recovery and Iraq Accountability Appropriations Act of 2007 (Public Law 110-28). Michigan Medicaid policy bulletin MSA 08-03 provides the Center for Medicare & Medicaid Services' (CMS) guidelines related to the use of the tamper resistant prescription pads for the Medicaid Program. An FAQs guide is available at http://www.michiganpharmacists.org/index2.htm.

CHAMPS Provider Notices

Pharmacies that are also enrolled as a type 87 medical supplier with the Department should review the recent MDCH Policy Bulletin MSA 08-13 for upcoming CHAMPS changes. (Bulletin is posted on the Provider tab under "Bulletins".) Enrolled medical suppliers will soon receive a letter asking them to access the CHAMPS system and revalidate their enrollment information. This applies only to medical suppliers - not pharmacy providers. If you are a medical supplier and have questions about the letter you received, you can contact the CHAMPS hotline at 1-888-643-2408 or email CHAMPS@michigan.gov.

Prescription Origin Code

This is a reminder that beginning 04/01/2008, the Michigan Department of Community Health will require pharmacies to report the type of prescription presented at the pharmacy. Claims will deny if one of the following NCPDP values for the Prescription Origin Code are not submitted: 1 = Written, 2= Telephone, 3= Electronic, 4= Facsimile. Please refer to the Department's policy bulletin MSA-08-05 for more details. Refill claims submitted 4/1/2008 or later with original Prescription Date Written prior to 4/1/2008 will not reject if the Prescription Origin Code is not populated.

Elimination of Dispense Fees for Medical Supplies

Effective March 1, 2008, the Michigan Department of Community Health will no longer reimburse a dispensing fee for a medical supply covered under the pharmacy benefit. Please refer to the policy bulletin MSA-08-04 for more details. Click here for the bulletin. For your convenience, click here to retrieve a list of products that no longer have a dispensing fee. Please note that condoms dispensed under the pharmacy benefit will continue to be reimbursed without a dispensing fee.

Brand vs. Generic Drug Co-pay Changes

Effective April 1, 2008, due to a First DataBank coding change (elimination of Generic Price Indicator), the Michigan Department of Community Health (MDCH) will employ new variables to determine if drug products will incur the generic or brand co-pay. Some drug products that were previously assigned a $3 brand co-pay will now be assigned a $1 generic co-pay and vice versa. Notification of this change was sent to beneficiaries, who may inquire about their co-pay amount(s) at your pharmacy. To assist pharmacies in responding to inquiries on co-pay changes, click on the following lists to see the drug product(s) with an increase (click here) or decrease (click here) in co-pay amount. These lists should be used for your general reference. The point of sale system will return the beneficiary's co-pay amount that is in effect at the time of claim submission. MDCH Program(s) drug coverage limitations still apply (e.g., prior authorization, quantity limits, etc.).

January 2008

Prescriber NPI Requirement (now delayed until 01/15/2008)

The Michigan Department of Community Health (MDCH) is now postponing the Prescriber NPI requirement (previously planned to occur on 10/01/2007). Now, effective 01/15/2008, MDCH will accept only the Prescriber's NPI number in the Prescriber ID field. The Prescriber’s DEA # will no longer be accepted. This requirement applies to all pharmacy claims submitted at point-of-sale to First Health. When submitting claims using the Prescriber NPI, pharmacy service providers are reminded to submit a Prescriber ID qualifier of '01' in NCPDP field number 466-EZ. Claims will deny if Prescriber's NPI number is not submitted in the Prescriber ID field. Click here to search the national NPI Registry for Prescriber NPIs.
Please refer to the following MDCH policy bulletins for more information on MDCH NPI requirements:
1) MSA 07-17 Reporting the NPI with Prescription Orders and Prescription Drug Claims,
2) MSA 07-22 contains the Pharmacy NPI Contingency Plan and
3) MSA 07-48 end of MDCH NPI Contingency Plans and,
4) MSA 07-56 Announcing Prescriber NPI requirement delayed until 01/15/2008.

November 2007

Announcement concerning 10-digit ID numbers

Pharmacy providers should continue to report a 10-digit Cardholder ID (CØ2-C2) on NCPDP claims submitted to First Health. Apparently some confusion resulted after pharmacy providers received provider bulletin MSA 07-59 from the Michigan Department of Community Health's (MDCH) regarding the new 10-digit beneficiary IDs. To clarify further, if the beneficiary's ID is only 8 digits, two leading zeros should continue to be added so that the Cardholder ID submitted is 10-digits as usual. However, for newer IDs that are actually 10 digits, no leading zeros are needed. Additional questions pertaining to this provider bulletin should be directed to MDCH Provider Inquiry via email at ProviderSupport@michigan.gov or phone toll-free 1-800-292-2550.

October 2007

Michigan Pharmacy Quality Improvement Project (PQIP)

The Michigan Department of Community Health (MDCH) is engaged in a collaborative project, entitled the Michigan Pharmacy Quality Improvement Project (PQIP) to provide information about the psychiatric medication utilization of Michigan medicaid patients. Educational alerts are sent to providers when patients are prescribed medications in ways that may vary from generally accepted evidence-based or consensus-based guidelines. This information can be linked to by selecting Committees > PQIP.

Provider associations were recently notified regarding changes to PQIP (see Association Notice). The document entitled "Child Behavioral Pharmacy Management Program Changes" (see Michigan PQIP Dosing Table), reflects highest customary doses for children and adolescents when prescribing behavioral health drugs. The PQIP workgroup composed of Prepaid Inpatient Health Plan and Michigan Medicaid Health Plan medical directors has reviewed these suggested changes and approved them for use in Michigan. This is informational only. Be aware any prescribing and treatment decisions must be based on the prescriber's clinical judgement and the patient's particular needs.

July 2007

Injectable Drugs

Effective 07/19/2007, an enhancement of the point-of-sale edits will prevent payment for physician administered injectable drugs that were being covered incorrectly as a pharmacy benefit. This change is in accordance with Section 1.4 in the Pharmacy Chapter and Section 4.13 in the Practitioner Chapter of the Michigan Medicaid Provider Manual. To link to this policy for additional information, click on Providers >> Manuals. When following the rules of a primary insurance, there may be instances that an exception to cover as a pharmacy benefit would be appropriate. These exception requests and questions related to coordination of benefit claim submission should be directed to the First Health Technical Call Center at 877-864-9014.

MOMS Drug Coverage

Effective 07/19/2007, point-of-sale edits will reflect MOMS program drug coverage. To review the list of covered products, click here or go to Providers>>Drug Information>>MOMS Drug Coverage.

New 07/01/2007- Pharmacy Level TPL Override

Pharmacies can now submit a pharmacy level override using Prior Authorization Type Code (461-EU) = '1' to override the NCPDP 70 - NDC Not Covered w/ additional transaction message "TPL amount collected must be greater than $2.00" instead of calling or faxing the First Health call center.

June 2007

Emergency Services Only Coverage (Update)

Effective 06/27/2007, refill claims submitted with dates of service 05/01/2007 or after will deny at point of sale for beneficiaries with Emergency Services Only Medicaid. For pharmacy coverage information for this beneficiary population, review the "Emergency Services Only" chapter of the Michigan Medicaid Provider Manual by clicking on Providers>>Manuals.

Announcing a new on-line tool for Pharmacy Prior Authorizations: WEB PA

The Michigan Department of Community Health, in conjunction with First Health Services Corporation, is pleased to offer an alternative means to submit pharmacy prior authorization (PA) requests for prescription drugs. This web-based process is designed to save prescribers time by providing a real-time pharmacy prior authorization. This process will supplement the more traditional means of requesting PAs by phone or fax, which will still be available to providers. The product will be available on Monday, June 4, 2007. In order to use WebPA, provider designees will need to register to receive a log on and password for the WebPA system. Detailed information on user registration, including a web based tutorial, can be accessed by clicking here. For more information about WebPA, including a tutorial and a complete instruction manual click here. For questions or assistance with registration, call the First Health Services Web Support Call Center at 1-800-241-8726.

Looking for WebPA? Check under the Pharmacy tab above, or click here.