Current through Register Vol. 56, No. 6, March 18, 2024
(a) For pharmacy claims with service dates on or after May 3, 1999, that exceed DUR Board standards, the PAAD program shall utilize the medical exception process (MEP) to allow the override of a claim denial, when medically necessary.
1. The MEP may be administered by a vendor on behalf of the Department.
2. All pharmacy claims shall be subject to the MEP regardless of claims media, except that claims from long-term care facility providers shall be exempt from the PDUR and MEP until notice is issued otherwise.
(b) The MEP shall be as follows:
1. Upon the occurrence of a PDUR edit indicating that a claim is denied unless a medical exception override is applied, the pharmacist shall contact the MEP contractor.
2. The MEP contractor shall approve the claim for payment for the full prescription specified, or a 30-day supply of the prescription, whichever amount is less, unless it is clear that consumption of the prescribed medication poses a threat to the patient's life or may result in a potentially serious illness based on the information available to the pharmacist and the MEP contractor.
3. If the prescription exceeds a 30-day supply, the MEP contractor shall send the prescriber an MEP Prescriber Notification Letter form, along with the PAAD beneficiary's name and PAAD identification number, the dispense date, drug quantity and drug description, and the toll-free telephone number of the MEP contractor.
4. In order to request the medical exception override, the prescriber shall submit the completed MEP Prescriber Notification Letter to the MEP contractor with a justification for the medical exception override, and the anticipated length of time the medical exception override for the PAAD beneficiary will be necessary to satisfy the length of therapy required.
5. The MEP contractor shall render a decision on the request for the medical exception override documented in the completed MEP Prescriber Notification Letter, basing the decision whether to grant or deny the request upon drug standards and protocols established by the DUR Board, and shall notify the PAAD beneficiary, the prescriber and the pharmacist of the decision.
6. If the request is approved, the MEP contractor shall issue an authorization number recognized by the NJMMIS for the medical exception override to facilitate claim payment.
(c) Except as (b)2 above applies, the PAAD program shall deny payment for claims subject to the MEP process for which an authorization number has not been issued by the MEP contractor.
(d) PAAD beneficiaries, or prescribers acting with the consent of the PAAD beneficiary, and pharmacies (following receipt of a Remittance Advice Statement) may request a fair hearing to appeal a decision by the MEP contractor not to approve a claim pursuant to (b)2 or 5 above within 30 calendar days following the date of the claim denial, in accordance with 10:167-6.12.
1. The request for a fair hearing shall be made in writing, and shall specify the reasons the PAAD beneficiary, pharmacy or prescriber believes that the MEP's decision was incorrect.
2. The request for a fair hearing shall be submitted to:
PAAD MEP
PO Box 715
Trenton, NJ 08625-0715
