MedicaidPrior AuthHigh impact
MAB2026083102
Pennsylvania Medicaid (DHS)·PA · Pharmacy·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Sep 1, 2026
Summary
Effective October 1, 2026, Pennsylvania Medical Assistance (MA) will implement new billing procedures for Emergency Medical Assistance (EMA) beneficiaries. All drug claims for MA-covered drugs dispensed to EMA-eligible noncitizens will require prior authorization to confirm medical necessity for treating the identified emergency medical condition. A 5-day emergency supply may be dispensed without prior authorization while authorization is pending. Billing teams must update systems to flag EMA beneficiaries, implement prior authorization workflows, and apply emergency level-of-service indicators.
Action Required
By September 15, 2026: Billing team must implement the following changes: (1) Update billing software to flag all patients with EMA eligibility status (identified via EVS system message or NCPDP/ePrescribing transactions); (2) Configure system to require prior authorization for ALL MA-covered drug claims for EMA beneficiaries before processing, with exception for initial 5-day emergency supply; (3) Train pharmacy staff and prescribers to recognize EMA eligibility messages and understand that 5-day emergency supplies may be dispensed without prior auth while authorization requests are submitted; (4) Update claim billing procedures to include Level of Service code 3 (EMERGENCY) for NCPDP/Internet claims or Emergency Indicator Y for 837 Professional claims when billing 5-day supplies; (5) Ensure prior authorization requests follow Section I procedures in the Prior Authorization of Pharmaceutical Services Handbook; (6) Update patient communication protocols to ensure EMA beneficiaries are informed in writing before service that certain non-emergency services (preventive, screening, vaccinations, non-emergency dental/vision, family planning, routine antepartum/postpartum care, chiropractic, hospice, organ transplants) are NOT covered under EMA. Non-compliance will result in claim denials for drugs requiring prior authorization without proper authorization documentation.