2016 CMS Part D Prescriber Validation Requirements

Posted on Jan 06, 2016

Effective January 1, 2016, prescriptions will no longer be covered under Medicare Part D if written by a prescriber who does not have a valid Type 1 NPI. When a claim rejects due to an inactive, invalid or missing NPI and cannot be resolved at the point of sale, the pharmacy must provide information to the beneficiary explaining the reason the claim could not be covered under Medicare Part D.
Medicare Part D Plans must reject the claim if:
 Non-NPI is submitted
 Type 1 NPI is inactive
 Invalid NPI is submitted (e.g. Type 2 NPI)
Claims will reject and pharmacies can no longer use the submission clarification code (SCC) 49 – “Type 1 NPI unavailable” to communicate with the plan sponsor. SCC 42 – “Submitted Prescriber ID is Active and Valid with Appropriate Prescriptive Authority” will be permitted.
In the event a claim rejects for invalid Prescriber ID, please review the following steps.
 Verify the submitted NPI is a Type 1 – Individual. If the Prescriber’s NPI is not a type 1, call the Prescriber to obtain the individual Prescriber NPI.
 Validate the NPI online by using the CMS NPI checker: https://nppes.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do
Please note – For controlled substance prescribing, a prescriber must have an active DEA identifier in good standing and have the authority to prescribe a controlled substance in a given DEA drug class schedule (2, 2N, 3, 3N,4, and 5), but the appropriate SCC value can be used to override the rejection. You can
You can validate a Prescriber’s DEA at https://www.deadiversion.usdoj.gov/webforms/validateLogin.jsp.