Date: December 17, 2019
To: Enrolled Pharmacies
Re: Critical Access Pharmacy (CAP) Program Professional Dispensing Fee
This notice provides information related to the professional dispensing fee for pharmacies defined as Critical Access Pharmacies. The professional dispensing fee applies only to fee-for-service claims. It does not apply to claims billed to HealthChoice Illinois managed care plans or Medicare-Medicaid Alignment Initiative (MMAI) plans.
In an informational notice dated August 22, 2019, the Department announced a Centers for Medicare and Medicaid Services (CMS) State Plan approved reimbursement methodology, which includes a higher professional dispensing fee for pharmacies that meet the definition of Critical Access Pharmacy within the State Plan. This State Plan approved reimbursement methodology is unrelated to the Critical Access Pharmacy quarterly payment program that was passed by the Illinois General Assembly in 2018 as described in an informational notice dated March 8, 2019.
On September 12, 2019, the Department implemented the new professional dispensing fee retroactive to July 15, 2019. The professional dispensing fee for these Critical Access Pharmacies (CAPs) will be $15.55 for both single and multiple source drugs.
All pharmacies that meet the State Plan CAP criteria, including those already identified by the Department, must attest to meeting the State Plan CAP criteria within 30 days of the date of this notice in order to receive the State Plan CAP professional dispensing fee effective July 15, 2019. Those pharmacies that do not attest within 30 days of the date of this notice will only receive the State Plan CAP professional dispensing fees prospectively.
Any eligible pharmacy not currently receiving the State Plan CAP Professional Dispensing fee of $15.55 must void and rebill all claims processed between July 15, 2019 and Sept 12, 2019, in order to receive the corrected professional dispensing fee for those claims.
Pharmacies that experience rejections attempting to void and rebill, or have any questions regarding this notice, may contact a pharmacy billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.