Provider Notice issued 08/09/2023

This notice implements Public Act 102-1051 that allows pharmacists to be reimbursed for human immunodeficiency virus (HIV) pre- and post-exposure prophylaxis assessment and consultation. This new policy is effective with dates of service on and after January 1, 2023, and applies to the Medicaid fee-for-service (FFS) program and the HealthChoice Illinois (HCI) managed care organizations (MCOs).

In accordance with the Act, the Department of Healthcare and Family Services (HFS) will cover patient care services provided by a pharmacist for HIV pre- and post-exposure prophylaxis  assessment and consultation at 85% of the physician rate. Pharmacists must have a standing order with an associated physician licensed to practice medicine in all its branches and be enrolled in the Illinois Medical Assistance Program in order to perform the assessment and consultation services. 

HFS Enrollment to Provide HIV Pre- and Post-Exposure Prophylaxis Assessment and Consultation  225 ILCS 85/43.5 states a pharmacist wishing to provide these services to a patient must complete an educational training program accredited by the Accreditation Council for Pharmacy Education (ACPE) and approved by the Illinois Department of Financial and Professional Regulation (IDFPR) that is related to the initiation, dispensing, or administration of drugs, laboratory tests, assessments, referrals, and consultations for HIV pre- and post-exposure prophylaxis. 

• An enrolled pharmacist wanting to be reimbursed for HIV pre- and post-exposure prophylaxis assessment and consultation services must modify their current enrollment in the IMPACT system by answering a checklist question that asks if they have completed a training program that meets the training requirements set forth in the Act and is accredited by ACPE. If the pharmacist answers “yes” to the checklist question, this will prompt HFS staff to update the provider’s file to allow billing for the service. 

• The pharmacist also needs to associate themselves to a pharmacy who will act as the pharmacist’s payee/billing provider. 

• Claims may be submitted after the pharmacist receives an updated Provider Information Sheet noting the addition of Category of Service 132.

Billing

Pharmacies billing on behalf of pharmacists will submit claims in the 837P electronic format, for CPT procedure code 99401 - Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes.  CPT 99401 must be billed without a modifier. 

One of the following Evaluation and Management procedure codes may also be billed for the assessment component of the service: 

• The pharmacist must have a standing order from a physician and the physician must be identified as the ordering/prescribing provider. 

• The pharmacist’s National Provider Identifier (NPI) must be identified as the rendering/servicing provider.

• The pharmacy’s NPI must be identified as the billing provider.

• The Place of Service code must be “01”

Drugs dispensed will continue to be billed through the pharmacy billing system. 

As a reminder, Public Act 102-1051 states that services provided shall be appropriately documented and retained in a confidential manner consistent with State HIV confidentiality requirements. In case of HFS audit, providers must be able to supply adequate documentation to support the services provided.

Payment

Pharmacist rates for the above CPT procedure codes are identified in a separate Pharmacist Fee Schedule on the Department’s website. 

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or to the applicable HCI MCO plan.

Kelly Cunningham, Administrator

Division of Medical Programs