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 a 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 0460, 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) Only original forms are accepted