N.J. Admin. Code § 10:51-1.27

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:51-1.27 - Medical exception process (MEP)

(a) For pharmacy claims with service dates on or after September 1, 1999, which exceed prospective drug utilization review (PDUR) standards recommended by the New Jersey DUR Board and approved by the Commissioner of the Department of Human Services (DHS) and the Commissioner of the Department of Health (DOH), the Division of Medical Assistance and Health Services has established a medical exception process (MEP) for Medicaid and NJ FamilyCare fee-for-service pharmaceutical services.

(b) The medical exception process shall be administered by a contractor, referred to as the MEP contractor, under contract with the Department of Human Services (DHS).

(c) The medical exception process shall apply to all pharmacy claims, regardless of claim media, unless exempted by the New Jersey DUR Board and the Commissioners of DHS and DOH in accordance with the rules of those Departments.

(d) The medical exception process is as follows:

1. Pharmacy providers shall be notified when submitting a claim that a prescription is limited to a maximum 30-day supply.

2. The pharmacy shall be responsible to contact the MEP contractor to decide if a medical exception is needed. If an exception is needed, the pharmacist may dispense medication for up to a 30-day calendar period. During this period, the MEP contractor shall issue a Prescriber Notification Letter which may include, but is not limited to, requesting from the prescriber the reason for the medical exception, diagnosis, expected duration of therapy, and the expiration date for the medical exception.

3. Following review and approval, if appropriate, of a prescriber's written justification, the MEP contractor shall override existing PDUR edits through the issuance of a prior authorization number.

4. The MEP contractor shall notify the pharmacy and prescriber of the results of the review by the close of the 30-day calendar period, and shall include, at a minimum, the beneficiary's name, mailing address, HSP number, the reviewer, service description, service date, and prior authorization number, if approved, the length of the approval and the appeals process if the pharmacist does not agree with the results of the review.

5. Pharmacies may request a fair hearing to appeal decisions rendered by the MEP contractor concerning denied claims (see N.J.A.C. 10:49-10, Notices, Appeals and Fair Hearings.)

6. Claims subject to the medical exception process which have exhausted the 30-day allowance period and for which prior authorization has not been issued by the MEP contractor shall be denied payment by the Medicaid/NJ FamilyCare programs.

N.J. Admin. Code § 10:51-1.27

Amended by 48 N.J.R. 2785(a), effective 12/19/2016