NYRx Pharmacy Rejections: Key Updates for Physicians
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Attention all healthcare providers: Important changes have been made regarding NYRx pharmacy claim rejections. It’s crucial to understand the reasons behind claim denials and how to resolve them effectively.
- Prior Authorization Requirement: Only one type of rejection necessitates a prescriber obtaining prior authorization (PA). For instance, if the rejection code is related to the necessity of a PA, pharmacies should contact the prescriber and resubmit once PA is obtained.
- Early Refills: Claims may be rejected if attempted too soon. NYRx allows refills only after 75% of the previous fill is used, with a more stringent rule applied for controlled substances. Pharmacies should inform patients about the earliest possible refill date instead of requesting a PA.
- Other Insurance: If a patient has additional insurance coverage, claims should be submitted to all other payors before NYRx. NYRx acts as the last resort payer, and no PA is needed for claims denied due to other insurance coverage.
- Therapeutic Drug Utilization Reviews and Quantity Limits: Pharmacies can often override these rejections at the point of sale and should adjust the claim submission accordingly without seeking a PA from prescribers.
For further details on resolving specific rejection codes and comprehensive resources, visit the NYRx Education & Outreach website or contact their support team at 1-833-967-7310.
