Effective May 23, 2008, 2003 Wisconsin Act 272 mandates that providers may not disclose a practitioner’s federal registration number without consent. Under this act, prescribing providers may decline to authorize the use of their Drug Enforcement Agency number for claims and prior authorizations, except when used on a prescription order for a controlled substance. Violators of the provisions to Wisconsin Act 272 are subject to financial penalties.
2003 Wisconsin Act 272
Effective May 23, 2008, 2003 Wisconsin Act 272 mandates that providers may not disclose a practitioner's federal registration number without consent. Under this act, prescribing providers may decline to authorize the use of their Drug Enforcement Agency (DEA) number for claims or prior authorizations (PAs), except when used on a prescription order for a controlled substance. Violators of the provisions to Wisconsin Act 272 are subject to financial penalties.
Conducting Business Under Wisconsin Act 272
As of May 19, 2008, Wisconsin Medicaid and BadgerCare Plus accept a National Provider Identifier (NPI) and/or a Medicaid provider number on Health Insurance Portability and Accountability Act of 1996 standard electronic transactions.
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Other business functions will continue to require eight-digit Medicaid provider numbers until ForwardHealth interChange implementation in October 2008. |
National Council for Prescription Drug Programs Version 5.1
As of May 19, 2008, Wisconsin Medicaid and BadgerCare Plus accept an NPI or a DEA number in the prescriber ID field on Point-of-Sale (POS) real-time pharmacy claims. If the billing provider is unable to obtain the prescriber’s NPI or permission to use the prescriber’s DEA number, then the billing provider should submit the appropriate default DEA, as detailed in this BadgerCare Plus Update, for the prescriber or the pharmacy’s NPI .
The hierarchy for submitted prescribing provider identification numbers for real-time pharmacy claims to Wisconsin Medicaid and BadgerCare Plus is the following:
- Prescribing provider's NPI.
- Prescribing provider's DEA number, with permission.
- Default DEA number or the pharmacy's NPI.
Paper Claims and Prior Authorizations
Wisconsin Medicaid and BadgerCare Plus will not accept a NPI on paper claims or paper PAs until ForwardHealth interChange implementation in October 2008. However, providers are required to adhere to the provisions of Wisconsin Act 272 when submitting paper.
The following are guidelines for submitting paper claims and paper PAs:
- If a billing provider submits an NPI on a Noncompound Drug Claim form, HCF 13072 (fillable PDF, 82 KB) (06/03) or Compound Drug Claim form, HCF 13073 (fillable PDF, 115 KB) (06/03), the claim will be denied. A valid DEA number must be entered for the prescriber.
- If a billing provider submits an NPI on a paper PA, the PA will be returned. A valid DEA number must be entered for the prescriber.
If the provider is unable to obtain permission to use the prescriber's DEA number, then the appropriate default DEA should be indicated for the prescriber.
STAT-PA
Wisconsin Medicaid and BadgerCare Plus will not accept a NPI on Specialized Transmission Approval Technology-Prior Authorizations (STAT-PAs) until ForwardHealth interChange implementation in October 2008. However, providers are required to adhere to the requirements of Wisconsin Act 272 when submitting STAT-PAs.
If a provider submits an NPI for a STAT-PA, the PA will be returned. A valid DEA number must be entered for the prescriber. If the provider is unable to obtain permission to use the prescriber's DEA number, then the appropriate default DEA number should be entered for the prescriber.
Default Drug Enforcement Agency Numbers
Providers are required to adhere to the provisions in Wisconsin Act 272, stating that DEA numbers cannot be required on claims and PAs. Therefore, if a billing provider is unable to obtain the prescriber provider's NPI or permission to use the prescriber's DEA number after a reasonable effort, then a "default" DEA number may be used. The following are the default DEA number options:
- XX5555555 — to be indicated when permission to use the prescriber's DEA number cannot be obtained.
- XX9999991 — to be indicated when the prescriber does not have a DEA number.
Information Regarding Managed Care
This Update contains fee-for-service policy and applies to services members receive on a fee-for-service basis only. Pharmacy services for members enrolled in the Program of All-Inclusive Care for the Elderly (PACE) and the Family Care Partnership are provided by the member's managed care organization. Managed care organizations must provide at least the same benefits as those provided under fee-for-service.
