Attention Pharmacies: Hospital Based Presumptive Eligibility (HBPE)
Hospital Based Presumptive Eligibility (HBPE)
Part of the Affordable Care Act (ACA) gives hospitals the authority to issue Medicaid Identification Numbers to patients who, based on self-reporting, qualify for Medicaid services. Once this number is issued, it will cover payment for medical services and prescriptions for the recipient for up to sixty (60) days. (In that time frame, the member receiving the number will be required to provide documentation of eligibility for Medicaid in order for coverage to continue.)
The numbers issued by hospitals for in-patient and emergency room services will be transmitted to the Medicaid Point of Sale System within 24-72 hours. Because of the time required for eligibility file updates, some Medicaid members may present a card (example below) at the pharmacy with an identification number that is not yet found in the system.
Please be assured that these members do have coverage and their identification numbers will be in the POS system within 24-72 hours. If possible, please dispense these member’s prescriptions or the portion required until the Medicaid ID number can be verified in the usual manner. Members are assured of thirty days coverage, allowing for your claims to be billed in a timely manner. Hospitals will begin issuing identification numbers for eligible members on January 10, 2014.
Please direct any questions to Vicki.M.Cunningham@wv.gov or call 304-558-1700 and ask for Pharmacy Services. Thanks for your help in providing healthcare for West Virginia’s uninsured population.