Current through Register Vol. 56, No. 18, September 16, 2024
(a) For pharmacy claims that exceed DUR Board
standards, the Senior Gold 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 institutionalized
beneficiaries 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 claims 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 (MNF) form, along with the Senior Gold
beneficiary's name and Senior Gold 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 Senior
Gold 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 Senior Gold 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 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) Senior Gold beneficiaries or
prescribers acting with the consent of the Senior Gold 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 N.J.A.C 10:167B-6.12.
1. The request for a fair hearing
shall be made in writing, and shall specify the reasons the Senior Gold beneficiary, pharmacy or prescriber
believes that the MEP's decision was incorrect.
2. The request
for a fair hearing shall be submitted to:
Senior Gold MEP
