CurrentNeighborhood Health Plan of Rhode IslandPolicy 114 P.L. 255

Cures Act screening and enrollment of Medicaid providers

This document explains Rhode Island's implementation of the federal 21st Century Cures Act requiring Medicaid providers and pharmacies to be screened and enrolled with the State Medicaid Agency and describes consequences for non-compliance affecting MCOs and members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCures Act screening and enrollment of Medicaid providers

Policy CodePolicy 114 P.L. 255

Change TypeInformational (no material change)

Effective DateJul 1, 2023

Next Review DateN/A

Key ActionProviders and pharmacies must be screened and enrolled with the State Medicaid Agency; non-compliance will result in pharmacy claim denials at point of sale effective July 1, 2023.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1, 2018federal enrollment deadline

Jul 1, 2023claim denial effective

42 CFR 438.602(b)regulatory citation

1single application

Enrollment Compliance and Member Impact

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Enrollment compliance and member guidance

Consequences and guidance related to provider enrollment status:

ALL of the following

Providers and pharmacies must be screened by and enrolled with the State Medicaid Agency by January 1, 2018 per the 21st Century Cures Act (114 P.L. 255) and 42 CFR 438.602(b).
Continued non-compliance will result in pharmacy claim denials at point of sale, effective July 1, 2023.
Member guidance
- Members experiencing rejected claims at point of sale should be advised to go to a different pharmacy that is enrolled with State Medicaid.
- If contacted by multiple managed care plans to enroll with RI Medicaid, providers need submit only one application.

Regulatory and program references: 21st Century Cures Act (114 P.L. 255); 42 CFR 438.602(b).

Relevant Dates and Coding Notes

Inventory placeholder codesmixed

No codes listed

inv-03: enrollment deadline

Federal Cures Act deadlineJanuary 1, 2018

Regulatory requirementScreening and enrollment required under 42 CFR 438.602(b)

ScopeApplies to all Medicaid providers and pharmacies to be screened and enrolled with the State Medicaid Agency

State implementerRhode Island EOHHS responsible for screening and enrolling all MCO providers and pharmacies

Requirements and Consequences for Providers and Pharmacies

Denial Risk

Screening and enrollment required; non-compliance leads to POS pharmacy claim denials

Providers and pharmacies must be screened by and enrolled with the State Medicaid Agency (RI EOHHS). Continued non-compliance will result in pharmacy claim denials at point of sale effective July 1, 2023.

Deadline for screening and enrollment per the Cures Act: January 1, 2018.
If a member’s claim is rejected at point of sale, advise the member to go to a different pharmacy that is enrolled with State Medicaid.
If contacted by multiple MCOs to enroll, submit a single application to RI Medicaid.

Key Terms

inv-05: screened and enrolled

DefinitionScreening and enrollment: the state-administered process required for Medicaid providers and pharmacies to be authorized to participate and bill for Medicaid services.

Who must enrollAll Medicaid providers and pharmacies participating with MCOs in Rhode Island

Single applicationIf contacted by multiple managed care plans, providers need only submit one application to RI Medicaid.

Consequence of non-complianceContinued non-compliance will result in pharmacy claim denials at point of sale effective July 1, 2023.