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1. Verify if a/b has any private health insurance coverage for prescription drugs including a Part D provider.

2. Deduct the amount of reported charges for prescription drugs above the monthly Medicaid prescription limit which are either not covered by third party insurance or deduct the unpaid balance that remains after insurance has paid.

3. Because they exceed the monthly Medicaid prescription limit for the same drugs, for ease of administration you may refer the physician to the Claims and Billing website. This guide outlines the requirements for overriding the monthly Medicaid prescription limit when the life of the patient would be threatened without the additional drug(s) and includes a copy of the override request form. Or refer to the Focused Risk Management Program (FORM). Refer to MA-2905, Medicaid Covered Services, for more information on FORM. Beneficiaries under the age of 21 or residents of intermediate care facilities/mental retardation centers, skilled level of care facilities and beneficiaries residing in assisted living facilities and group homes are exempt from the monthly Medicaid prescription limit.

4. For Medicare beneficiaries, refer to MA-2312, Medicare Prescription Drug Benefits. C. Physician Charges Charges for physicians' services may be deducted as UMNs if the physician refuses to accept Medicaid and the criteria in VIII. A., above is met. 1. Determine if the reported charges are covered by the a/b's Part B Medicare coverage. (Refer to MA-2360, Medicaid Deductible, V.C.)

a. If the a/b is a Medicare beneficiary and provides a bill for physician's services on a date already authorized for Medicaid, advise the representative to provide the Medicaid information to the provider.

b. The balance of the total charge after Medicare payment (if EOB used) or 20% of the charge may be used as unmet medical needs if the individual was not yet authorized for Medicaid on the date of service and the provider refuses Medicaid now. 2. The county may give the provider the MID number and the Medicaid eligible dates for which the provider has charges.

a. Physicians and suppliers are required to file Medicare claims for all patients who are Medicare beneficiaries.

b. Physicians and suppliers are required to accept assignment if they are enrolled with Medicare in the Participating Physician and Supplier Program.

c. Do not deduct physician charges for a Medicaid beneficiary who has Medicare Part B coverage. Docusign Envelope ID: 950E9248-29CC-8930-81BC-BCEC667EB493