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

Cures Act screening and enrollment of Medicaid providers and pharmacies

This document notifies Medicaid providers, pharmacies, MCOs, and members in Rhode Island about the Cures Act requirement that providers and pharmacies be screened and enrolled with the State Medicaid Agency and the operational consequence of claim denials for non-enrolled pharmacies effective July 1, 2023.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCures Act screening and enrollment of Medicaid providers and pharmacies

Policy CodePolicy 114 P.L. 255

Change TypeInformational / Operational

Effective DateJul 1, 2023

Next Review Date

Key ActionPharmacies must be enrolled with State Medicaid or claims will be denied at point of sale beginning July 1, 2023.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1, 2018enrollment deadline (Cures Act)

Jul 1, 2023point-of-sale denial effective

1single application required

Cures Act Compliance and Operational Effects

Compliance and point-of-sale denial guidance

Operational consequences and member guidance for providers and pharmacies that are not screened and enrolled with the State Medicaid Agency:

Compliance requirements

Providers and pharmacies must be screened by and enrolled with the State Medicaid Agency by January 1, 2018 as required by the 21st Century Cures Act (114 P.L. 255) and 42 CFR 438.602(b).

Consequences of non-compliance

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

Member guidance when claims are rejected

Members experiencing rejected claims at point of sale should be advised to go to a different pharmacy that is enrolled with State Medicaid.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCures Act screening and enrollment of Medicaid providers and pharmacies

Policy CodePolicy 114 P.L. 255

Change TypeInformational / Operational

Effective DateJul 1, 2023

Next Review Date

Key ActionPharmacies must be enrolled with State Medicaid or claims will be denied at point of sale beginning July 1, 2023.

SourceLink

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Operational note on enrollment applications

If contacted by multiple managed care plans, providers and pharmacies need only submit a single enrollment application to RI Medicaid.

Key Dates and Coding Notes

Not applicablemixed

No codes listed

Enrollment requirement effective date

Enrollment requirement effective dateJanuary 1, 2018

Governing authority21st Century Cures Act (114 P.L. 255)

Regulatory citation42 CFR 438.602(b)

Responsible State agencyRhode Island Executive Office of Health and Human Services (EOHHS)

Mandatory Actions for Providers and Pharmacies

Denial Risk

Point-of-sale denials for non-enrolled pharmacies

Pharmacies not enrolled with State Medicaid will have pharmacy claims denied at point of sale beginning July 1, 2023. Members experiencing rejected claims at point of sale should be advised to go to a different pharmacy that is enrolled with State Medicaid.

Effective date for denials: July 1, 2023
Member guidance: advise members with rejected claims to use an enrolled pharmacy

Documentation Required

Mandatory screening and enrollment with State Medicaid

Providers and pharmacies must be screened and enrolled with the State Medicaid Agency as required by the 21st Century Cures Act and 42 CFR 438.602(b). If you receive communication to enroll from multiple managed care plans, submit only one application to RI Medicaid.

Cures Act requirement: screen and enroll with State Medicaid by January 1, 2018
Single application: only one application required even if contacted by multiple MCOs

Definitions and Program Components

Screening and enrollment by State Medicaid Agency

DefinitionScreening and enrollment by the State Medicaid Agency: the process required under the 21st Century Cures Act for Medicaid providers and pharmacies to be screened and enrolled with the State Medicaid Agency.

PurposeTo ensure MCO providers and pharmacies meet federal screening and enrollment requirements prior to participation in Medicaid.

ScopeApplies to all Medicaid providers and pharmacies, including those participating with managed care organizations (MCOs).

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