Date: December 19, 2019
To: All Medical Assistance Program Providers
Re: January 1, 2020 Requirements for Ordering/Referring/Prescribing Provider Enrollment and Managed Care Plan Adoption of HFS Preferred Drug List
This notice serves as a reminder regarding enrollment of providers who order, refer, or prescribe items or services for participants covered under the Department’s Medical Programs. It also informs providers that all managed care organizations (MCOs) will be required to adopt the Department’s Preferred Drug List (PDL).
Ordering/Referring/Prescribing (ORP) Provider Enrollment
Beginning January 1, 2020, any provider who orders, refers, or prescribes for a participant under the Illinois Department of Healthcare and Family Services’ Medical Programs must be enrolled and identified by a National Provider Identifier (NPI) on applicable claims submitted. Per the Patient Protection and Affordable Care Act section 6401(b) and subsequent federal regulations at 42 CFR 455.410(b) and 455.440, the Department is mandated to require this and is subject to federal audit. This applies to claims for persons with traditional fee-for-service coverage as well as a HealthChoice Illinois managed care plan, and an MMAI plan where a service is covered all or in part by Medicaid.
The informational notice dated September 23, 2019 regarding ORP providers contains links to earlier policy releases. Providers not enrolled must go to the IMPACT webpage to start the enrollment process. The Department has made available an Illinois Medicaid Provider Directory housed on the IMPACT home page. The directory may be used to verify enrollment of a provider in the Illinois Medical Assistance Program.
MCOs to Adopt the Department’s Preferred Drug List (PDL)
Beginning January 1, 2020, all MCOs will be required to adopt the Department’s PDL. The MCOs will align their drug coverage with the Department’s so that they and the Department’s fee-for-service program have the same preferred and non-preferred products listed on their PDLs. Generally, the MCOs cannot require prior authorization for any drug on the PDL for which the Department does not require prior authorization; however, they are not required to adopt the Department’s clinical prior authorization criteria for drugs on the Department’s PDL. In addition, the MCOs cannot be more restrictive than the Department regarding age limitations or days’ supply allowed for PDL products.
Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for fee-for-service claims, or to the applicable MCO.