Early Fill Letter to Providers
September 2, 2008
Dear Medicaid Pharmacy Provider:
Effective October 1, 2008, the Medicaid program will implement an early fill edit which will deny drug claims when less than 75% of the previously dispensed amount has been used. The determination of an early fill will be applied to all claims for the same drug product and strength, regardless of prescribing provider, billing provider, or prescription number.
The following information describes the early fill editing process:
Via eMedNY, an early fill response is returned to the pharmacist if a prescription claim is transmitted prior to the date when 75% of the previous supply would have been used if taken according to the prescriber's directions. The eMedNY claim denial message will indicate the reason for denial and specify the date that is the earliest the prescription claim will be accepted for payment.
When medically necessary, pharmacists will be able to override denials at the point of service by using a combination of the Reason for Service code, Result of Service Code and the Submission Clarification Code as follows:
| Field Description | Action |
|---|---|
| Reason for Service Code Field 439-E4 | ER-Overuse |
| Result of Service Code Field 441-E6 | Appropriate Result of Service Code |
| Submission Clarification Code Field 420-DK | "03" Vacation Supply "04" Lost Prescription |
Pharmacists should use code 03 when the early fill is for vacation or travel purposes. Code 04 should be used when an early fill is needed because the enrollee's medication has been lost, damaged/destroyed, or stolen.
Please note that pharmacists are responsible for ensuring that early fills involving controlled substances, including the pharmacist override provision, are compliant with all controlled substance law, regulation and policy.
For questions regarding this new payment system edit, please call the eMedNY Call Center at 800-343-9000. For questions regarding pharmacy reimbursement policy, contact the Bureau of Pharmacy Policy and Operations at 518-486-3209.
Sincerely,
Linda J. Jones, R.N., Director
Bureau of Pharmacy Policy and Operations
Office of Health Insurance Programs
