Nevada Medicaid and Nevada Check Up News (First Quarter 2021 Provider Newsletter) [Read]

Attention Behavioral Health Providers: Monthly Behavioral Health Training Assistance (BHTA) Webinar Scheduled [See Web Announcement 2009]

Attention All Providers: Requirements on When to Use the National Provider Identifier (NPI) of an Ordering, Prescribing or Referring (OPR) Provider on Claims [Announcement 850]

If you are a Medicaid provider whose revalidation application has not been processed by your termination due date, you will be ineligible to provide services to any Nevada Medicaid or Nevada Check Up recipients, including both Fee-for-Service and Managed Care Organization (MCO) enrolled recipients. See Web Announcement 1265

Enrollment Termination Frequently Asked Questions (FAQs) [Review]

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Paper claims are no longer accepted by Nevada Medicaid. Please refer to Web Announcement 1733 and Web Announcement 1829 for additional information.

Top 10 Claim Denial Reasons and Resolutions/Workarounds for March 2021 Claims. Web Announcement 2472.

Top Prior Authorization Denial Reasons for the First Quarter of 2021. See Web Announcement 2505.

Top 10 Enrollment Return Reasons and Resolutions for First Quarter 2021 Submissions. See Web Announcement 2501.

Attention Providers Using the Authorization Criteria Function: Results that return prior authorization (PA) requirements are accurate. For results that return “There are no records found based on the search criteria,” there may be a PA requirement if limits have been exceeded. To verify PA requirements, please refer to the Medicaid Services Manual (MSM) Chapter for your service type at dhcfp.nv.gov and the Billing Guide for your provider type at www.medicaid.nv.gov.

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Pharmacy Billing Information

Billing Manual
Title Last Update
Pharmacy Billing Manual 05/26/21
Appendix A - Instructions for Completing the NCPDP Universal Claim Form (Ver 5.1) 02/04/14
Appendix B - NCPDP D.0 Payer Sheet for Pharmacy Providers 09/21/20
Appendix C - Other Carrier Code List 07/24/09
Appendix D - Quantity Limits 06/01/21
Appendix E - Drugs Not Requiring Whole Quantities 10/24/13
Billing Updates
Date Title
June 1, 2021 Attention Prescribers and Pharmacies: Nevada Medicaid Fee-for-Service Updates for Insulin Syringes
May 24, 2021 Attention Provider Type 28 (Pharmacy): Nevada Medicaid Fee-for-Service Update Regarding COVID-19 Vaccine Administration Reimbursement (Updated May 24, 2021)
April 6, 2021 Drug Use Review (DUR) Board Approves Changes Effective March 1, 2021
March 31, 2021 Prior Authorization Process for Zolgensma® (onasemnogene abeparvovec-xioi) for Fee-for-Service and Managed Care Organization Recipients
March 23, 2021 OptumRx Prior Authorization Process for Obtaining Additional Information
March 22, 2021 OptumRx Pharmacy Benefits Manager System Updates
Dec. 28, 2020 Updated Medicare Part D Benefit Co-Pay for 2021
Dec. 21, 2020 New Pharmacy Electronic Prior Authorization (ePA) System Implemented
Nov. 30, 2020 Drug Use Review (DUR) Board Approves Changes Effective November 30, 2020
Nov. 25, 2020 Urgent: Nevada Medicaid Pharmacy Services Issues Stop Coverage on Folixapure™ Effective November 25, 2020
Oct. 13, 2020 Respiratory Syncytial Virus (RSV) Prophylaxis with Synagis® (Palivizumab)
Oct. 2, 2020 Prescription Drug Coverage for Medication Assisted Treatment (MAT) Update
Sept. 24, 2020 Prescription Drug Coverage for Medication Assisted Treatment (MAT) (Updated October 2, 2020)
Sept. 21, 2020 Pharmacy Claims for Schedule II Drugs to Require Quantity Authorized by Prescriber
Aug. 31, 2020 Drug Use Review (DUR) Board Approves Changes Effective August 31, 2020
Aug. 28, 2020 DHCFP Issues Stop Coverage on Non-Rebate Products Effective August 28, 2020
Aug. 28, 2020 Addition of OneTouch® Blood Glucose Meter to Preferred Nevada Medicaid Diabetic Supply Program
Aug. 24, 2020 Urgent: Nevada Medicaid Pharmacy Services Issues Stop Coverage on Empricaine Kit II Effective August 21, 2020
Aug. 21, 2020 Attention Prescribers and Pharmacies: Emergency Regulation Restricting Prescribing and Dispensing of Hydroxychloroquine and Chloroquine during Novel Coronavirus (COVID-19) Pandemic Has Expired
Aug. 17, 2020 Billing Instructions for Pharmacy Point of Sale (POS) Claims Exceeding $999,999.99
Aug. 3, 2020 Drug Use Review (DUR) Board Approves Changes Effective August 3, 2020
July 17, 2020 Urgent: Nevada Medicaid Pharmacy Services Issues Stop Coverage on DermacinRx Products Effective July 17, 2020
May 14, 2020 Remdesivir Authorized for Novel Coronavirus (COVID-19) Treatment (Updated June 19, 2020)
May 4, 2020 Attention Pharmacies: Override on Restriction for Contraceptives During Postpartum Period
April 3, 2020 Attention Prescribers and Pharmacies: Temporary Prior Authorization Override to Allow Compounding of Certain Alcohol-Based Hand Sanitizer Products during Novel Coronavirus (COVID-19) Pandemic
March 27, 2020 Attention End Stage Renal Disease (ESRD) Facilities: Pharmaceuticals Included in Prospective Payment System (PPS)
March 25, 2020 Attention Prescribers and Pharmacies: Emergency Regulation on Prescribing and Dispensing Hydroxychloroquine and Chloroquine during Novel Coronavirus (COVID-19) Pandemic
March 20, 2020 Attention Prescribers and Pharmacies: Hydroxychloroquine and Chloroquine Diagnosis Requirements on Prescriptions and Guidance for Treatment of Novel Coronavirus (COVID-19) (Updated March 24, 2020)
March 17, 2020 CPT Code 90686 (Fluarix®) is FDA-Approved and is a Vaccine for Children (VFC) Vaccine
March 17, 2020 Pharmacy “Refill Too Soon Waiver” Implemented in Response to Coronavirus Disease (COVID-19) Threat
March 3, 2020 Updated Details Regarding Diabetic Supply Policy Changes
Feb. 28, 2020 Drug Use Review (DUR) Board Approves Changes Effective March 2, 2020
Feb. 27, 2020 DHCFP to Host Diabetic Supply Preferred Product Educational Webinar
Feb. 6, 2020 Updates to Diabetic Supply Policy Changes
Dec. 30, 2019 Diabetic Supply Policy Changes for Nevada Medicaid
Dec. 23, 2019 Medicare Part D Co-Pay Reimbursement Increase for 2020
Dec. 12, 2019 Medicaid Services Manual Chapter 1200 - Prescribed Drugs Updates
Dec. 4, 2019 Diabetic Supply Policy Changes for Nevada Medicaid
Dec. 2, 2019 Drug Use Review (DUR) Board Approves Changes Effective December 2, 2019
Nov. 15, 2019 Brand Voltaren® Gel Unavailable
Nov. 14, 2019 Diabetic Supply Policy Changes for Nevada Medicaid
Oct. 7, 2019 Respiratory Syncytial Virus (RSV) Prophylaxis with Synagis® (Palivizumab)
September 24, 2019 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (SUPPORT Act) Compliance
September 10, 2019 Urgent: Physician-Administered Drug (PAD) Claim Processing
September 3, 2019 Drug Use Review (DUR) Board Approves Changes Effective September 2, 2019
July 25, 2019 Update to Compounded Medications Prior Authorization Requirement
June 12, 2019 Compounded Medications Require Prior Authorization Effective June 3, 2019
June 12, 2019 New and Updated Pharmacy Prior Authorization Forms
May 31, 2019 Drug Use Review (DUR) Board Approves Changes Effective June 3, 2019
May 6, 2019 Nevada Medicaid Human Papillomavirus (HPV) Vaccine Policy Effective May 6, 2019
March 15, 2019 Drug Use Review (DUR) Board Approves Changes Effective February 4, 2019
March 14, 2019 Nevada Medicaid Drug Use Review Board Votes to Adopt Policy on Outpatient Antibiotic Medications
Dec. 10, 2018 Medicare Part D Co-Pay Reimbursement Increase
Nov. 8, 2018 DHCFP to Host Antibiotic Policy & Provider Education Webinar (Updated December 6, 2018)
Oct. 25, 2018 Respiratory Syncytial Virus (RSV) Prophylaxis with Synagis® (Palivizumab)
Sept. 10, 2018 Drug Use Review (DUR) Board Approves Changes Effective July 2, 2018
Aug. 6, 2018 Drug Use Review (DUR) Board Approves Changes Effective August 6, 2018
June 21, 2018 Pharmacy Announcement: Prior Authorization for High Dollar Claims will be Implemented August 6, 2018
June 20, 2018 Drug Use Review (DUR) Board Approves Changes Effective May 7, 2018
May 7, 2018 Prior Authorization Required for Mavyret™ and Vosevi®
Feb. 2, 2018 Drug Use Review (DUR) Board Approves Change Effective February 5, 2018
Jan. 2, 2018 Medicare Part-D Co-Pay Change
Dec. 29, 2017 Drug Use Review (DUR) Board Approves Changes Effective January 1, 2018
Dec. 22, 2017 Coverage Requirements for Contraceptive Drugs, Devices and Services to Implement on January 1, 2018
Oct. 6, 2017 Respiratory Syncytial Virus (RSV) Prophylaxis with Synagis® (Palivizumab)
Oct. 6, 2017 Insulin Quantity Limit Adjusted to Allow 65 to 120 Day Supply
Oct. 2, 2017 Legislative Assembly Bill AB473 Extends NRS 422.4025 Sunset until June 30, 2019
July 31, 2017 Drug Use Review (DUR) Board Approves Changes Effective August 1, 2017
May 5, 2017 Criteria for Practitioners to Dispense Medications
May 2, 2017 Drug Use Review (DUR) Board Approves Changes to MSM Chapter 1200
May 1, 2017 Quantity Limits Approved at January 2017 Drug Use Review Board Meeting
March 30, 2017 Opioid Therapeutic Class to be Added to Medicaid Services Manual (MSM) Chapter 1200 (Prescribed Drugs) (Updated April 28, 2017)
Feb. 23, 2017 Attention Prescribers and Pharmacies: Mandatory Three-Month Supplies for Maintenance Medications
Feb. 10, 2017 Pharmacy Announcement: Bypass Function Added for Claims for Children under Age 18 with a Diagnosis Related to a Seizure Disorder when Prescriber is a Neurologist (Updated March 24, 2017)
Dec. 30, 2016 Pharmacy Co-Pay Increase for Brand Name Medications for Dual-Eligible Medicare Recipients
Dec. 30, 2016 Pharmacy Announcement Regarding Claims for Snake Anti-Venom
Nov. 7, 2016 Drug Use Review Board (DUR) Approves Changes to MSM Chapter 1200 Effective November 9, 2016
Nov. 4, 2016 Pharmacy Benefit Manager Changes from CatamaranRx to OptumRx
Nov. 3, 2016 Nevada Medicaid Informational Bulletin on Medications and Services for Substance Use Disorders
Oct. 14, 2016 Drug Quantity Limits Effective October 17, 2016
Sept. 12, 2016 Instructions for Claims for Gender Identity Disorder Hormones
June 3, 2016 Drug Quantity Limits Effective May 16, 2016
May 20, 2016 New Prior Authorization Forms Available for Psychotropic Agents
May 4, 2016 Nevada Medicaid Will Use Federal Upper Limit Pricing Provided by Centers for Medicare & Medicaid Services for Outpatient Drugs
April 1, 2016 Update Regarding Psychotropic Medications for Children and Adolescents (Updated May 3, 2016)
March 1, 2016 Reminder to Pharmacy Providers: Document Counseling when Dispensing a Medication
Feb. 12, 2016 Narcan Nasal Spray Added to Preferred Drug List
Dec. 18, 2015 Quantity Limits for Sedative/Hypnotic Agents (Updated January 22, 2016)
Dec. 15, 2015 Psychotropic Medications for Children and Adolescents
Nov. 18, 2015 Urgent Pharmacy Announcement: Pricing Override Allowing Brand Products to Pay at Brand Price
Oct. 27, 2015 ICD-10 Diagnosis Code Reference for Drug Claims
Oct. 12, 2015 Open Provider Forums Scheduled Regarding: Pharmacy Dispensing Fee Increase and Pricing Methodology Using National Average Drug Acquisition Cost (NADAC) Files
Oct. 7, 2015 Future Changes to MSM Chapter 1200, Prescribed Drugs
Sept. 23, 2015 Pharmacy Dispensing Fee Increase and Pricing Methodology Using National Average Drug Acquisition Cost (NADAC) Files
Aug. 24, 2015 Naloxone to be Listed as Preferred on Preferred Drug List
Aug. 18, 2015 Pharmacy Dispensing Fee Increase and Pricing Methodology Using National Average Acquisition Cost (NADAC) Files
July 27, 2015 Quantity Limits for Hepatitis C Treatment Agents
July 21, 2015 Viekira Pak® Notification
July 1, 2015 Drug Use Review (DUR) Board Approves Changes to MSM Chapter 1200 Effective July 1, 2015
June 25, 2015 State Maximum Allowable Cost (MAC) Applied to Abilify® (Updated July 13, 2015)
March 24, 2015 Pharmacy Claims Payments to be Delayed One Week
March 13, 2015 Changes for Pharmacies and Prescribers of Psychotropic Medications for Children and Adolescents Have Been Removed from the Prior Authorization Form (Updated May 1, 2015)
Feb. 19, 2015 Duplicate Dispensing Fees on Claims for Long Term Care Pharmacy Dispensing IV Medications
Feb. 18, 2015 Drug Use Review (DUR) Board Approves Changes to MSM Chapter 1200 Effective January 1, 2015
Feb. 6, 2015 Attention Pharmacies: New Billing Instructions for Vaccine Claims when Submitted with a Non-participating Prescriber Due to Ordering, Prescribing and Referring (OPR) Practitioner Validation
Nov. 12, 2014 Use of Pharmacy Drug Discount Cards by Recipients and Retro-Eligible Refunds
Oct. 29, 2014 Update for Pharmacies: Override Period for Point-of-Sale Processing for Claims Adjudication Process to Validate Ordering, Prescribing and Referring (OPR) Practitioners Ends February 5, 2015 (Updated December 9, 2014, and January 9, 2015)
Oct. 28, 2014 Vaccines Administered by Pharmacies
Oct. 13, 2014 Copaxone® 20 mg Billing Update
Sept. 29, 2014 Hydrocodone Combination Products Change to DEA Schedule 2
Aug. 25, 2014 Drug Use Review (DUR) Board Approves Quantity Limits Effective September 9, 2014
July 16, 2014 Drug Use Review (DUR) Board Makes Changes to MSM Chapter 1200 Effective July 1, 2014
July 14, 2014 340B Drug Discount Program
May 29, 2014 Payment Delay for Claims for Newly Eligible/Childless Adults
Apr. 11, 2014 URGENT: Pharmacy Claims Payments to be Delayed One Week
Mar. 26, 2014 Quantity Limit for Promethazine with Codeine Cough Syrup
Feb. 12, 2014 Prescription Co-pay Increases for Dual-eligible Recipients
Feb. 4, 2014 Billing Instruction for Benzodiazepines and Barbiturates for Dual-Eligible Recipients
Jan. 7, 2014 Policy Reminders for Covered and Non-covered Medication Process for Hospice Recipients
Aug. 16, 2013 Ritalin LA® Reimbursed at Available Wholesale Acquisition Cost (WAC)
Aug. 9, 2013 Actual Acquisition Cost (AAC) for Pharmacy Products That Do Not Have Other Pricing on File
July 17, 2013 Recipient's Date of Birth to be Required on Pharmacy Claims
July 16, 2013 Vaccine/Immunization Information for Pharmacies
Jan. 4, 2013 Reimbursement for Secondary Claims for Medicare Part B Covered Drugs
May 2, 2012 Pharmacist-Administered Adult and Childhood Immunizations Covered by Nevada Medicaid and Nevada Check Up
Apr. 25, 2012 FDA Acetaminophen Dosage Announcement
Mar. 15, 2012 EDI Announcement: March 31, 2012, End Date for Dual Use of NCPDP 5.1/D.0 and Extension of Dual Use for 4010/5010 Formats until June 30, 2012
Feb. 2, 2012 NCPDP D.0 Payer Sheet for Pharmacy Providers
Dec. 16, 2011 EDI Announcement: Nevada Medicaid Dual Use for 5010 and D.0 Formats
Dec. 14, 2011 NCPDP D.0 Testing Instructions (Updated Dec. 16, 2011)
Dec. 5, 2011 Specifications for NCPDP, v 5.1
Dec. 18, 2008 Prescription Origin Code Instructions Updated for 2009
Dec. 17, 2008 Annual Co-Payment Increase for Medicare Part D/Medicaid Dual-Eligible Recipients
May 15, 2008 NPI Reminder: Use Prescriber’s NPI on Pharmacy Claims
Mar. 27, 2008 DHCFP Issues Guidance Regarding Tamper-Resistant Prescription Pads
Mar. 12, 2008 Revised Tamper-Resistant Prescription Pads and Prescription Origin Code Notification
Jan. 2, 2007 2007 Co-Payment Increase for Medicare Part D/Medicaid Dual-Eligible Recipients
Nov. 8, 2006 Nevada Prescriber List Posted Online
July 10, 2006 Billing Notice for Medicaid Recipients with Medicare Part B and/or Part D
June 14, 2006 $2/$5 Co-Payment Claims for Medicare Part D/Medicaid Recipients
June 2, 2006 Tolerances Modified for Controlled Substance Refills
May 10, 2006 Revised Co-Payment Billing Instructions
Feb. 21, 2006 Co-Payment Claims for Medicare Part D / Medicaid Recipients
Co-Payment Functionality is Now Available
Jan. 25, 2006 Billing Instructions for Part D Dual Eligible Recipients
Jan. 24, 2005 Co-Payments for Medicare Part D / Medicaid Dual Eligibles
Dec. 20, 2005 Medicare Part D Prescription Billing Information
Dec. 16, 2005 Upcoming Nevada Medicaid Changes
Feb. 25, 2005 Multi-ingredient Compound Claims, Partial Fill Functionality & Provider Training