Provider Notice issued 02/18/14

Chapter P-200, Handbook for Providers of Pharmacy Services Revision to Recipient Restriction Referrals – HFS1662

The purpose of this Bulletin is to inform providers of a department change regarding the billing process for participants that have been restricted to a specific primary care physician and have been prescribed medication from someone other than the primary care physician. Effective with the date of this notice, providers should follow the process outlined below when dispensing and billing for a medication when the prescriber is someone other than the primary care physician to whom the participant has been restricted.

If the participant is restricted to a Primary Care Physician and the Primary Care Physician refers the client to another physician/specialist who prescribes medications to the participant, then the referring physician (physician to whom the participant is restricted) or the pharmacy must either download the HFS 1662 from the Healthcare and Family Services Medical Programs Forms webpage or call the Recipient Restriction Program (RRP) unit at 800-325-8823 and request a HFS 1662 form (Primary Care Provider Authorization form). The completed HFS 1662 is then given to the dispensing pharmacy which is required to retain the HFS 1662 form (paper or electronic copy), for auditing purposes, for a period of 7 years.

The pharmacy can then bill electronically NCPDP D.O standard as follows-

The referred physician/specialist should be identified on the claim as the prescribing physician in the Prescriber ID field (411-DB) and the referring physician (physician to whom the participant is restricted) should be identified on the claim as the primary care physician in the Primary Care Provider ID field (421-DL). If a problem occurs with the submission of the claim, the pharmacy should contact a department Pharmacy Billing Advisor at 877-782-5565, option 7 for assistance.

The Department will not pay for restricted services that are provided on a non-emergency basis without prior written authorization of the designated Primary Care Physician. This authorization will be in the form of a completed Form HFS 1662.

Providers who have questions about a participant's RRP status may call the Department's toll-free RRP hotline at 1-800-325-8823.

Questions regarding this notice should be directed to the Bureau of Professional and Ancillary Services at 1-877-782-5565, Option 7.

The handbook notice will replace Section P-210 Recipient Restriction Program of the Pharmacy Handbook. The Handbook for Providers of Pharmacy Services (pdf) has been updated and is available on the department's Web site. Any questions regarding this bulletin should be directed to your facility's medical assistance consultant in the Bureau of Comprehensive Health Services at 1-877-782-5565.

Instructions for updating the Handbook for Providers of Pharmacy Services:

P-210 Recipient Restriction Program - Remove pages HFS P-210 and insert new page HFS P-210.