IMPORTANT NOTICE TO PROVIDERS REGARDING THE PURCHASE, BILLING AND ADMINISTRATION OF J CODE DRUGS IN THE OFFICE AND OUTPATIENT FACILITY SETTING
Date: 06/01/21
What Networks are Impacted? MeridianHealth (Medicaid) and YouthCare
In accordance with the Department of Health and Family Services (HFS) directions and to align with the Illinois Association of Medicaid Health Plan (IAMHP) billing guidelines, MeridianHealth and Youthcare will be implementing a new process the billing of drug codes; specifically medications administered in the provider’s office (J code drugs).
What will happen beginning July 1, 2021 with the Administering Provider and Pharmacy:
- Prescribers purchase the medication directly from the pharmacy and submit a claim to the health plan directly (buy and bill)
- Prescribers submit a prescription to the pharmacy; pharmacy submits the claim to the pharmacy benefit manager (PBM) (MeridianRx or Envolve Pharmacy Solutions). Once a paid claim is obtained by the pharmacy, the medication can be dispensed to the Prescriber.
Pharmacy claims billing information
| MeridianHealth | YouthCare |
RxBIN | 610241 | 020545 |
RxPCN | MHPILMCD | RXA383 |
RxGroup |
| RXGMCIL01 |
Claims for medications submitted to the health plan by the provider types listed below can bill for medications. Claims submitted to the health plan from pharmacies will be denied and should be billed to the PBM.
Provider type |
10-Physicians |
11-Dentists |
12-Optometrists |
13-Podiatrists |
16-Nurse Practitioners |
30-General Hospitals |
32-Rehabilitation Hospitals |
40-Federally Qualified Health Centers |
43-Encounter rate clinic |
46-Ambulatory Surgical Treatment Centers |
48-Rural Health Clinics |
50-Home Health Agencies - In Home |
52-Certified local public health department |
56-School Based / Linked Health Clinics |
64-Imaging Services |
70-Ambulance Service Providers |
89-Physician Assistant Only(Encounter Only) |
Please reference IAMHP guidelines beow;
If you have any questions regarding this new process, please contact your assign Provider Relations Representative
Sincerely,
YouthCare HealthChoiceIllinois