Pharmacy: Billing Issue with Early Refill Codes

HCA Apple Health

PROVIDER ALERT

Washington Apple Health (Medicaid), administered by the Health Care Authority (the agency), is aware of an ongoing billing issue with early refill codes. The agency is working on this issue and hopes to have it resolved as soon as possible. The following codes are affected:

Justification Description                                                    Code

Lost or Stolen Drug Replacement                                            5
School or Camp                                                                       8
Monitoring                                                                                8
Suicidal Risk (SR)                                                                    8
Take Home Supply (Skilled Nursing Facility Client)                8 

When using  these codes, you should manually override claims for clients who meet the justification under pages 71 and 72 of the Prescription Drug Program Provider Guide

For rejected claims, call the agency’s Pharmacy Authorization department at 1-800-562-3022 ext. 15483  between 8:30 a.m. and 4:30 p.m. weekdays.  

If a client’s medical needs are urgent, based on the dispensing pharmacist’s professional judgment, and you are unable to receive prior authorization by either fax or phone, the agency encourages you to follow its Emergency Fill Policy and obtain authorization after the fact when the Pharmacy Authorization department is available.  

The agency apologizes for any inconvenience.