Date: October 31, 2022
To: Enrolled Pharmacies; Physicians; Physician Assistants; and Advanced Practice Registered Nurses
Re: Pharmacists Billing for Hormonal Contraceptive Assessment and Consultation per Public Act 102-0103 Effective August 1, 2022
This notice implements the section of Public Act 102-0103 that allows pharmacists to bill and be reimbursed for patient care services for hormonal contraceptives. This new policy is effective with dates of service on and after August 1, 2022 and applies to the Medicaid fee-for-service (FFS) program and the HealthChoice Illinois (HCI) managed care organization (MCO) plans.
In accordance with the Act, the Department of Healthcare and Family Services (HFS) will cover patient care services provided by a pharmacist for hormonal contraceptive assessment and consultation at 85% of the physician rate. Pharmacists must have a standing order with an associated physician, licensed to practice medicine in all its branches and enrolled in the Illinois Medical Assistance Program, in order to perform the consultation service.
HFS Enrollment to Provide Contraceptive Assessment and Consultation
225 ILCS 85/43 states a pharmacist wishing to dispense hormonal contraceptives to a patient must complete an educational training program accredited by the Accreditation Council for Pharmacy Education (ACPE) and approved by the Illinois Department of Financial and Professional Regulation (IDFPR) that is related to patient self-screening risk assessment, patient assessment contraceptive counseling and education, and dispensation of hormonal contraceptives.
- An enrolled pharmacist wanting to be reimbursed for contraceptive assessment and consultation services must modify their current enrollment in the IMPACT system by answering a checklist question that asks if they have completed a training program that meets the training requirements set forth in the Act and is accredited by ACPE. If the pharmacist answers "yes" to the checklist question, this will prompt HFS staff to update the provider's file to allow billing for the service.
- The pharmacist also needs to associate themselves to a pharmacy who will act as the pharmacist's payee/billing provider.
- Claims may be submitted after the pharmacist receives an updated Provider Information Sheet noting the addition of Category of Service 103.
Pharmacies billing on behalf of pharmacists will submit claims in the 837P electronic format, for CPT procedure code 99401 - Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes.
- Procedure code modifier FP (Family Planning) must be billed in conjunction with procedure code 99401.
- The pharmacist must have a standing order from a physician and the physician must be identified as the ordering/prescribing provider.
- The pharmacist's National Provider Identifier (NPI) must be identified as the rendering/servicing provider.
- The pharmacy's NPI must be identified as the billing provider.
- The Place of Service code must be "01".
Oral contraceptives dispensed will continue to be billed through the pharmacy billing system.
The pharmacist rate for CPT procedure code 99401 is $25.50. A separate tab has been added to the Practitioner Fee Schedule to identify this rate paid to pharmacists.
Questions related to pharmacists billing for contraceptive assessment and consultation may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or to the applicable HCI MCO plan.
Kelly Cunningham, Administrator
Division of Medical Programs