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Elizabeth M. Whitehorn, Director

Provider Notice issued 02/22/2024

 

To:
 Enrolled Pharmacies 
​Date: ​February 22, 2024
​Re: Temporary System Outage for Fee-For-Service (FFS) Pharmacy Billing

The Department wishes to notify pharmacies that Change HealthCare, an Optum affiliate, is experiencing a nationwide outage. Change Healthcare operates the Pharmacy Benefit Management System (PBMS) for the Department’s FFS billing application. This billing application is currently unavailable, with no estimated timeframe for returning to operation.

During this time, we are removing all prior authorization (PA) mandates, including Preferred/Non Preferred status, Refill Too Soon (RTS), Third Party Liability (TPL), and Four Prescription Policy (4Rx). In an effort to keep our population healthy and safe, we request that pharmacies, in good faith, continue to fill prescriptions at the prescribed quantity, not to exceed a 30-day supply, to eligible customers. Once the system is operational, the Department will make providers whole and assist with claim submissions and provide any necessary overrides.

The Department will pay all clean claims submitted once the PBMS system is operational; therefore, providers should not bill, demand, or otherwise seek reimbursement from that individual (or representative of the individual) for any service for which reimbursement is available from the Department in accordance with the Handbook for Providers of Medical Services, section 101.3.

For questions regarding a customer’s eligibility, you may utilize the MEDI system, call the hotline at 800-252-8942, or contact a pharmacy billing representative by calling  877-782-5565 and selecting Option 7.

Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.

 

Kelly Cunningham, Administrator
Division of Medical Programs