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Elizabeth M. Whitehorn, Director

Provider Notice issued 03/06/2024

 

To:
 Enrolled Physicians; Physician Assistants; Advanced Practice Registered Nurses; Local Health Departments; Federally Qualified Health Centers; Encounter Rate Clinics, and Rural Health Clinics
​Date: ​March 6, 2024
​Re: Practitioners - No Prior Approval for Drug Items During Change Healthcare Outage – Fee-for-Service Program Only

This notice contains information for practitioners who request prior approval through the Department of Healthcare and Family Services’ (HFS) fee-for-service (FFS) program for drug items administered in the office setting. Prior approval of practitioner-administered drugs is currently impacted by HFS’ vendor, Change Healthcare, that operates the Pharmacy Benefit Management System (PBMS) for the FFS program. Change Healthcare continues to experience a system outage due to its nationwide cyber security breach.   

According to the Handbook for Practitioner Services, practitioners may be reimbursed for certain practitioner-administered drugs that have been purchased by the practitioner and administered in the office setting. These drug claims are submitted on the 837 Professional claim format.

Some of these drugs require prior approval. The HCPCS codes for practitioner-administered drugs that require prior approval are identified in the Practitioner Fee Schedule with Note N – “Prior approval (PA) required for practitioner-purchased and administered drugs. Please reference the Pharmacy webpage for PA guidelines. Drug PA is obtained through Pharmacy.”     

Due to the current Change Healthcare system outage, practitioners are unable to obtain prior approval. HFS is allowing practitioners to submit claims for these drugs without prior approval for dates of service affected by the system outage and will not reject those claims for that reason. In doing so, customer care will not be delayed. Drugs that normally require prior authorization will not be subject to a post approval process.

HFS expects practitioners to continue to provide timely access to high quality care during this period of the nationwide outage.

Providers should monitor provider notices daily for information regarding resolution of the system outage and resumption of prior authorization requirements. Providers are strongly encouraged to subscribe to email notification of provider notices if they have not already done so.

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

 

Kelly Cunningham, Administrator
Division of Medical Programs