Diagnosis, Concurrent Medications and Step Care, and First Fill coverage rules currently are paying and reporting a message back to the pharmacy for the Medicaid Expansion population.
The diagnosis coverage rule will deny starting January 21st for the Medicaid Expansion population. There will be no difference between the Traditional and Expansion Medicaid populations for the diagnosis coverage rule.
As a reminder
If you have submitted a claim for a drug that requires a diagnosis code and you didn’t not submit a code or you submitted a code for a non-covered or invalid code, the claim will reject with NCPDP Reject “39-INV DIAGNOSIS CODE”.
If the diagnosis is not included on the prescription, please call to get the diagnosis and write it on the prescription, the same as any other part of the prescription you may clarify when needed. Diagnosis will be accepted for compendia and FDA indications.
Concurrent Medications and Step Care and First Fill
These coverage rules will deny and report at a later date (probably March) when we have enough claim history in our system to electronic look back for the required medication fills.
For more information on coverage rules please visit www.hidesigns.com/ndmedicaid and navigate to Coverage Rules on Medications.
Thank you for all of your support on making a successful transition.
Alexi Murphy, PharmD
Quality and Operations Manager, Pharmacy Services
701.328.4061 (office) • 701.328.1544 (fax)
600 E. Boulevard Ave – Dept 325 • Bismarck, ND 58505-0250
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