Attention Medicaid Providers: New PMP Rule Goes into Effect Oct. 1, 2021
What is the Rule?
In an effort to address opioid abuse in the United States, in 2018, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act was signed into law. Part of this new law, section 5042, mandates that all state Medicaid programs require Medicaid providers to check a prescription drug monitoring program (PMP) prior to prescribing a controlled substance (Schedule II through Schedule IV), not just opioids, to a Medicaid patient. The Health Care Authority (HCA) has filed a permanent rule regarding the SUPPORT Act that will become effective Oct. 1, 2021 and impact all Apple Health (Medicaid) providers who prescribe controlled substances.
How Do I Comply?
To comply with the rule, prior to prescribing any controlled substance to an Apple Health patient, the provider must check the Washington State PMP no more than 10 days before writing the prescription. The PMP check must review the most recent 12-month period of prescription drug history of the patient, the provider must review the number and type of controlled substances prescribed and filled as well as who prescribed a controlled substance, and the date and time of this review must be recorded in the patient’s record. The task of checking the PMP may be delegated to anyone who has authorization to access the PMP, as long as the required information is relayed to the treating provider before the provider prescribes a controlled medication. In the case that the PMP is inaccessible, or the provider is unable to access it, a “good faith” effort must be documented in the patient’s record, along with the reason or reasons the provider was unable to conduct the check and the provider’s intention to attempt the PMP check at a later date.
Health Care Authority Compliance Checks
The HCA will monitor PMP checks by matching the date written on prescriptions in claims data with the PMP log data. A check inside of the 10-day appointment window will count as a qualified check and a check outside of that timeframe will count as an unqualified check. If there is no PMP review recorded for a prescription, the prescription will be documented as unchecked. The HCA may send educational letters to prescribers when less than 80% of a prescriber’s PMP checks are considered qualifying checks.
The PMP rule will become effective Oct. 1, 2021, and these changes will be reflected in the Oct. 1 Prescription Drug Program Billing Guide. For more information, please visit the HCA SUPPORT Act website.
