Newsletter Vol. 20, No.28

By January 15, 2011: Pharmacy billing team must complete Form FD-70 (Pharmacy Provider Certification Statement Rev. 11/2010) in full, attach a copy of the valid pharmacy permit, and submit to Molina Medicaid Solutions, P.O. Box 4804, Trenton, NJ 08650-4804, Attn: Form FD-70. ALL questions on the form must be completed or the form will be returned. By February 15, 2011: If form is not received by this date, the State will automatically assign only the basic dispensing fee without optional increments ($0.15 Impact Allowance and $0.11 24-Hour Emergency Service) to all pharmacy claims. Update billing system to reflect qualifying fee increments only if Form FD-70 is properly submitted and received. Notify pharmacy owner/operator of Impact Allowance requirement (minimum 50% combined NJ FamilyCare/Medicaid/PAAD/ADDP/CF/Senior Gold prescription volume as primary payer) and 24-Hour Emergency Service requirements (must certify actual 24/7/365 service at specific location with posted notice and emergency phone number). Establish internal process to notify Molina Medicaid Solutions in writing within 30 days if Impact Allowance or 24-Hour Emergency Service status changes. Consequences of non-compliance: Claims will be reimbursed at basic dispensing fee only (without $0.26 increments), and if State later determines requirements were not met, the State will recover all reimbursement for increments retroactive to certification date.