Clarifying Pharmacy Billing of Claims Under OPRA

New York State Department of Health (DOH) recently issued a clarification concerning certain pharmacy claims that were rejected because the ordering/prescribing/referring/attending (OPRA) provider was an unlicensed resident, intern or a foreign physicians in training programs.

Under New York State law, unlicensed residents, interns or foreign physicians in training programs can legally prescribe and NYS Medicaid recognizes such prescriptions as valid so long as they are done under the supervision of a NYS Medicaid enrolled physician. While the rules do not require the supervising enrolled physician to sign a script alongside the doctor in training, for purposes of reimbursement, the script must include the NPI of the supervising/attending physician who is enrolled in Medicaid.

DOH advises pharmacies with rejected claims to resubmit and include the NPI of the supervising/attending physician enrolled in Medicaid. In cases where such NPI is unavailable and/or a pharmacy’s system only recognizes a single prescriber NPI, DOH recommends that pharmacies use specific override procedures.

If you have any questions regarding New York’s OPRA requirement, prescription and dispensing rules, or have any other legal questions, please contact our office.