Apple Health (Medicaid) Provider Alert
Dental-related prescriptions and prescriptions covered under
fee-for-service (FFS)
Dear pharmacy providers,
Washington Apple
Health, administered by the Health Care Authority, would like to remind
pharmacies that the following dental services for Apple Health clients are
covered under fee-for-service (FFS)—even for those clients whose primary
coverage is through an agency-contracted managed care organization (MCO):
- Dental-related prescriptions
- Prescriptions written by dentists
If a prescription is rejected by an MCO because it is
written by a dentist, please do not attempt to charge the client or turn the client
away.
For information
on additional products and services which are covered under FFS for MCO
clients, see pages 97 and 98 of the Prescription
Drug Program Billing Guide.
How do I handle these claims?
These claims must
be billed directly to the Health Care Authority, through FFS.
In some cases it
may not immediately be clear that the reason for rejection is that the
prescription was written by a dentist or dental surgeon. Depending on the
pharmacy benefit manager (PBM), claims may reject with reasons such as:
- “Restricted
Provider”
- “Prescriptive
Authority Restrictions Apply”
-
An
indication that the prescriber is out of network. If a prescription
for an MCO client is written by a dentist or prescribed for the purposes of
dental care, bill the claim directly to Washington Apple Health by entering
Prior Authorization Type Code 2 (field 461-EU of the Claim Segment in the NCPDP
claim standard).
|
