What is a Medicaid Override Form?
1. What is a Medicaid Override Request?
Medicaid pays for a specific number of physician visit, lab test, prescriptions. If you patient needs more than the usual alloted number, the NYS Office of Medicaid Managment will send them a Medicaid Utilization Threshold notice, requesting them to contact their physician for override of the service limits. Patient will then bring in these letters to you, requesting that you complete an Medicaid Override Form.
To complete this form, you will need the patient's Medicaid number,
address, start of his/her benefit month (all info are on the letter they
receive). You also need to fill out a list of ICD 9 codes to explain why
the patient is exceeding their threshhold. For the extreme cases- where you
think the patient would qualify more than the standard recommended override
numbers- you will need to write in a short narrative to provide an
explanation. Please also be sure to complete your mailing address,
license number (can use institutional-on all Rx pads/ or your attending’s), the provider code is 060, then sign and date the
form. Once the form is completed, you can either give the form to you front
desk staff to mail, or mail it to CSC Federal Sector CivilGroup POBOX 4602 Rensselaer
NY 12144-4602. For questions about
override program, call 1800 421 3891.
2 (blank forms are available in all registration areas and PIC rooms) Please note starting 4/2005 only original forms will be accepted, blank xerox forms will not be accepted.
