• The prescriber is valid and active and authorized by state and federal regulatory agencies to prescribe medications 
• The prescriber has a Type 1 NPI which must be submitted on the prescription claim. No other form of prescriber identification will be accepted. Any claim submitted with an invalid NPI will reject, but the appropriate SCC value can be used to override the rejection. This requirement is being applied to all claims since most health care providers are required to obtain and use an NPI as a standard identifier.  
• 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,4,5), but the appropriate SCC value can be used to override the rejection.

*Please see attached PDF for more information.

On April 16, 2015 the Medicare Access and CHIP Authorization Act of 2015 (MACRA) was signed into law. Section 507 of MACRA amends Section 1860D-4(c) of the Social Security Act by requiring that pharmacy claims for covered Part D drugs include an active and valid Type 1 National Provider Identifier (NPI). Beginning January 1, 2016 a Part D sponsor cannot pay a claim that does not include an active and valid prescriber NPI. Effective January 1, 2016 pharmacies must submit claims with an active and valid prescriber NPI – the SCC 49 value will be discontinued. The legislation invalidates the use of Submission Clarification Code (SCC) value 49 "Prescriber does not currently have an Active Type 1 NPI.” Claims without the NPI will reject with reject code 34 - M/I Sbm Clarification Cde If you have questions, please call the OptumRx Help Desk anytime:  UnitedHealthcare Medicare Prescription Drug Plans : 877-889-6481  UnitedHealthcare Medicare Advantage Prescription Drug Plans: 877-889-6510  All other plans: Use Toll-Free-Number on Member’s ID Card Please distribute

Date: December 21, 2015 Effective: January 1, 2016 Summary • Effective January 1, 2016, CMS requires that claims for covered Medicare Part D drugs must include active and valid prescriber NPIs; claims for both new prescriptions and refills without a qualifier for NPI and a valid NPI number will reject.