As the Department of Vermont Health Access (DVHA) has previously reported, Change Healthcare, which operates Vermont's Medicaid pharmacy claims system, experienced a significant cyber security issue on February 21, 2024. DVHA would like to thank Vermont Medicaid members for their patience and express appreciation for the work of pharmacies and providers continuing to serve members during this outage.
We are pleased to report that starting on March 18, 2024, pharmacy claims will begin processing again. Additionally, the Optum (parent company to Change Healthcare) helpdesk personnel are available to assist pharmacies with claims processing. Effective, March 18, 2024, providers and pharmacies may contact the helpdesk using the same pharmacy helpdesk number at 1-844-679-5362.
Information for submitting claims for drugs that were dispensed during the outage:
- Copays: Vermont Medicaid is removing copay requirements for all members for the duration of the outage. A $0.00 copay will be programmed on claims processed for dates of service throughout the outage (February, 21 – March 18, 2024). Vermont Medicaid will pay the entire claim amount, including any copay amount typically collected from the member. Pharmacies will not lose reimbursement for the copay amount.
- If a pharmacy has collected copays on any prescriptions dispensed during the outage, DVHA is asking those to be refunded to members as applicable.
- Pharmacies are encouraged to submit claims from the earliest date of service to the most recent date of service, to avoid incorrect processing due to sequencing of submissions.
- In an effort to reduce pharmacy burden, DVHA is bypassing condition codes:
- Reject Code 75 – PA Required.
- Reject Code 76 – Plan Limitations Exceeded.
- Reject Code 79 – Refill Too Soon.
- Prior Authorization: Pharmacies and prescribers are expected to follow Vermont Medicaid's Preferred Drug List requirements for non-preferred medications. For questions regarding prior authorization please call the Pharmacy helpdesk 1-844-679-5362.
- Please expect higher than average call volume to the helpdesk, as well as potential congestion with switch vendors (i.e. RelayHealth) during resubmission.
- If a pharmacy or provider would like to set up an appointment to work directly on troubleshooting submission of claims, please call the Optum helpdesk at 1-844-679-5362 to schedule a time to work through this process.
The Department is genuinely appreciative of the patience and understanding of members, pharmacies, and providers during this time. DVHA remains committed to transparency, and we will continue to provide updates and issue instructions for Medicaid members and prescribers.