N.J. Admin. Code § 10:66-1.8

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

Section 10:66-1.8 - Medical exception process (MEP)

(a) For pharmacy claims that exceed Prospective Drug Utilization Review (PDUR) standards recommended by the New Jersey DUR Board and approved by the Commissioners of DHS and DOH, the Division of Medical Assistance and Health Services has established a Medical Exception Process (MEP).

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

(c) The medical exception process shall apply to all pharmacy claims, regardless of claim media, unless there is a recommended exemption by the New Jersey DUR Board that has been approved by the Commissioners of DHS and DOH, in accordance with the rules of those Departments.

(d) The medical exception process is as follows:

1. The MEP contractor shall contact prescribers of conflicting drug therapies or drug therapies that exceed established PDUR standards to request written justification to determine medical necessity for continued drug utilization.

i. The MEP contractor shall send a Prescriber Notification Letter, which includes, but may not be limited to, the beneficiary name, Medicaid/NJ FamilyCare eligibility identification number, dispense date, drug quantity, and drug description. The prescriber shall be requested to provide the reason for medical exception, diagnosis, expected duration of therapy, and expiration date for medical exception.

ii. The prescriber shall provide information requested on the Prescriber Notification to the MEP contractor.

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

3. The MEP contractor shall notify the pharmacy and prescriber of the results of their review and include at a minimum, the beneficiary's name, mailing address, Medicaid/NJ FamilyCare eligibility identification 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.

4. Prescribers 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.

5. Claims subject to the medical exception process which have not been justified by the prescriber within 30 calendar days shall not be authorized by the MEP contractor and shall not be covered.

N.J. Admin. Code § 10:66-1.8

Amended by 49 N.J.R. 1405(a), effective 6/5/2017