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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 below;

If you have any questions regarding this new process, please contact your assign Provider Relations Representative

Sincerely,

MeridianHealth