At Navitus, we value the relationships that we have developed with prescribers and realize the importance of a strong, healthy rapport in support of member health. Following is a list of frequently asked questions from prescribers. For even more information, including formularies and prior authorization forms, click on the prescribers login button.
Pharmacy and Practitioner Exclusion Troubleshooting
Navitus Health Solutions regularly monitors lists which may indicate that a practitioner or pharmacy is excluded from providing services to a government program. This may include Medicare, Medicaid or any payers who are participating in government programs. Navitus will flag these excluded practitioners and pharmacies to reject claims from processing.
Many Medicaid programs also consider a pharmacy or practitioner to be excluded if that pharmacy or practitioner is excluded from any other State Medicaid Program. While one Medicaid program may not list all other state exclusions on its own list, the laws of that state automatically include other state exclusions.
Exclusion has a variety of causes including fraud, licensing issues, enrollment errors, or other reasons. The reason for exclusion may not be given. Navitus does not know the reason for exclusion and does not regulate exclusion. This is done at the State or Federal level.
To resolve an exclusion, the practitioner or pharmacy must contact the source(s) responsible for its exclusion. Navitus cannot remove the exclusion. Navitus also cannot process claims until the pharmacy or practitioner is cleared by the excluding entity.
Suggestions for Resolution:
- Review license(s) to ensure that any license is free of restrictions or disciplinary actions that may trigger exclusion
- Contact the excluding entity
- OIG LEIE - https://oig.hhs.gov/contact-us/index.asp#exclusions or 202-691-2311
- GSA SAM – www.sam.gov or www.fsd.gov or 866-606-8220
- Medicaid (by State)
- Contact each State Medicaid program that has a listed exclusion for the practitioner and/or pharmacy
- Ask about the reason for exclusion and your options for resolving it
- Verify that the excluding entity has the correct pharmacy or practitioner
- Verify the length of the exclusion
- If a State Medicaid Program says a pharmacy or practitioner is not on the exclusion list in the given state, why is it still being excluded by Navitus?
If that State Medicaid Program has a law or statute that prohibits other state Medicaid exclusions, the other states’ Medicaid exclusions would also apply. A state will generally only list the pharmacies or practitioners it has investigated and excluded. A state will not list other states’ exclusions.
- If a State Medicaid Programs says an excluded practitioner is not prohibited from prescribing, why isn't Navitus processing claims prescribed by the practitioner?
Prescribing is part of medical practice and is permitted under a practitioner’s state license. A practitioner may still be licensed, which allows prescribing. If the practitioner is also excluded, exclusion is a separate sanction. Even if the practitioner can prescribe under a state license, the exclusion prevents payment for the claims.
- How long does the exclusion last?
This varies based on the reasons used to exclude the practitioner or pharmacy. Medicare exclusions are usually no less than 5 years, with the length of exclusion listed on the OIG sanction. Medicaid programs may not list the length of exclusion.
- How often are exclusion lists updated?
OIG and GSA exclusion lists are updated monthly. Most Medicaid programs are updated monthly with some delays. Exclusion lists usually show the effective date of the exclusion but may not always show the end date. When an end date is reached, the excluded pharmacy or practitioner is usually removed from the list.
- If a pharmacy that was excluded is purchased by a new owner, will that pharmacy remain on the exclusion list?
It is likely that the pharmacy name will remain on the list until the new owner works with the appropriate entity to clear the exclusion.