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Background:
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
  • 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