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What to Do When Your Medicare Part D Prescriptions Are Denied

Wednesday, June 1, 2016   (0 Comments)
Posted by: Brook Schales
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What to do when your Medicare Part D Prescriptions get Denied
Laura Culberson Farr | Executive Director, OANP

You should by now have all received notices that effective June 1st, all healthcare providers who prescribe Part D medications for Medicare patients must be enrolled in Medicare or have an opt-out affidavit. But because Naturopathic Doctors are not recognized by Medicare, you can neither enroll in, nor opt out of Medicare.

Your Part D prescriptions should still be covered

Little known rules within Medicare allow exceptions for certain “other authorized providers” – including naturopathic physicians - to write prescriptions and have those orders covered.

Despite frequent requests from the OANP and others, it is unclear how much this information has been clearly disseminated to pharmacies and insurers that sponsor Part D plans.

Here’s what you need to know and some tools to help you advocate for your self and your patients if a pharmacy or Medicare plan denies coverage of a prescription.

Provide these materials to any pharmacy or Part D sponsor (insurance plan) that denies a prescription or referral from you as an ND.

1. On May 1, 2015, CMS issued a press release recognizing that many states authorize providers who are not recognizable by Medicare to prescribe legally. The press release cites an Interim Final Rule written to “mitigate potential interruptions to beneficiaries’ access to needed medications.”

2. On December 29, 2015 CMS issued a Technical Guidance document clarifying that plans must continue to cover prescriptions written by “Other Authorized Prescribers.” This document specifically highlights naturopathic physicians as an “OAP” and outlines how plans can identify claims for prescriptions written by “OAPs” (see page 4).

3. In February, 2016, OANP confirmed instructions with the CMS Center for Program Integrity that Naturopathic Doctors may issue Part D prescriptions and referrals, but you must ensure that your NPI is active and registered with the correct taxonomy for “Naturopath.” To verify your NPI/Taxonomy:

Step 1: Validate that your NPI number is active. Follow this link and enter your name in the search field. Then click on your hyperlinked NPI number to access details. In the top section under details, confirm that your status says “active.”

Step 2: Verify that your NPI number is correctly associated with the taxonomy code for naturopathic doctors – 175F00000X. A little further down the Provider Information page for your NPI number above, look for taxonomy.

You may encounter many pharmacies and Medicare Part D sponsors (insurance plans) that have not configured their systems to automatically recognize the ND taxonomy as an “Other Authorized Prescriber,” which will cause a denial in coverage.

Please feel free to use these materials to advocate on behalf of your patients to make sure they can still access their Medicare prescription benefits!

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