Q.

What does 2003 Wisconsin Act 272 mandate?

A.

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 prohibit their Drug Enforcement Agency (DEA) number to be indicated on claims or prior authorizations (PAs).

Q.

How does Act 272 affect claims and prior authorizations?

A.

2003 Wisconsin Act 272 means that a DEA number cannot be required on claims and PAs.

Q.

How can claims and prior authorizations be submitted if the billing provider is unable to obtain the NPI and does not have consent to use the DEA number from the prescribing provider?

A.

The billing provider is required to adhere to the requirements of 2003 Wisconsin Act 272. If the billing provider is unable to obtain the prescriber’s NPI or permission to use the prescriber’s DEA number after a reasonable effort, then a “default” DEA number or the pharmacy’s NPI (electronic claims only) may be submitted on the claim or PA for successful processing.

In October 2008 with the implementation of ForwardHealth interChange, NPIs will be required and DEA numbers will no longer be accepted.

Q.

How does Act 272 affect National Council for Prescription Drug Programs Version 5.1 transactions?

A.

Effective May 19, 2008, BadgerCare Plus accepts an NPI or a DEA number for the prescriber ID on National Council for Prescription Drug Programs Version 5.1 (NCPDP 5.1) transactions.

If the billing provider is unable to obtain permission to use the prescriber’s DEA number and is unable to obtain the prescriber’s NPI after a reasonable effort, then a “default” DEA number may be submitted on the NCPDP 5.1 transaction.

Q.

What is an appropriate default DEA number?

A.

If the prescriber’s DEA number is not obtained after a reasonable effort, there are two 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.

Providers who regularly and systematically use DEA numbers may be audited. For claims submitted through a software company, providers should check to ensure that a default DEA is not being automatically applied to claims in lieu of a valid DEA number.

Q.

Are there circumstances in which a default DEA number is not acceptable?

A.

Default DEA numbers will not be accepted on claims for controlled substances. State and federal regulations prohibit the use of default DEA numbers on prescriptions for controlled substances.

Q.

What issues may incur from using a default DEA number in lieu of the prescriber’s valid DEA number?

A.

Although it is acceptable for a billing provider to indicate a default DEA number on claims and PAs, providers should be aware that for Drug Utilization Review (DUR), targeted interventions, lock-ins, and audits, the valid DEA number for the prescriber yields useful information that will not be available when substituting a default DEA.

When a default DEA number is indicated on a claim, the following explanation of benefits message (EOB 887) will appear on the Remittance and Status Report: “Default prescribing physician number was indicated. Valid numbers are important for DUR purposes. Please obtain a valid number for future use.”

Q.

How does Act 272 affect Specialized Transmission Approval Technology-Prior Authorizations?

A.

It is important to note that Specialized Transmission Approval Technology-Prior Authorizations (STAT-PAs) will not accept an NPI until the implementation of ForwardHealth interChange in October 2008. If a provider enters a STAT-PA with an NPI prior to implementation, the PA will be returned.

The billing provider is required to adhere to the requirements of 2003 Wisconsin Act 272 for STAT-PA. If the billing provider is unable to obtain permission to use the prescriber’s DEA number, then a default DEA number may be entered for the prescriber.

 Q.

How does Act 272 affect paper Compound Drug claims and Noncompound Drug claims?

A.

It is important to note that paper Compound Drug Claim form, HCF 13073 (06/03), and Noncompound Drug Claim form, HCF 13072 (06/03), will not accept an NPI until the implementation of ForwardHealth interChange in October 2008. If a paper claim is submitted with an NPI prior to implementation, the claim will be denied.

The billing provider is required to adhere to the requirements of 2003 Wisconsin Act 272 for paper claims. If the billing provider is unable to obtain permission to use the prescriber’s DEA number, then a default DEA number may be submitted on the claim.

Q.

How does Act 272 affect paper PAs and attachments?

A.

It is important to note that paper PAs will not accept an NPI until the implementation of ForwardHealth interChange in October 2008. If a paper PA is submitted with an NPI prior to implementation, the PA will be denied.

The billing provider is required to adhere to the requirements of 2003 Wisconsin Act 272 for paper PAs. If the billing provider is unable to obtain permission to use the prescriber ’s DEA number, then a default DEA number may be submitted on the PA.