N.J. Admin. Code § 10:58A-2.5

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:58A-2.5 - 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 Drug Utilization Review Board (NJ DURB) and approved by the Commissioners of the Department of Human Services (DHS) and the Department of Health (DOH), the Division of Medical Assistance and Health Services has established a medical exception process (MEP). See N.J.A.C. 10:51.

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

(c) The MEP shall apply to all pharmacy claims, regardless of claim media, unless there is a recommended exemption by the NJ DURB, which has been approved by the Commissioners of DHS and (DOH), in accordance with the rules of those Departments.

(d) The MEP 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 Medical Necessity Form (MNF), which includes, but may not be limited to, the beneficiary name, Health Benefits Identification (HBID) number, dispense date, drug quantity and drug description. The prescriber shall be requested to provide the reason for the medical exception, diagnosis, expected duration of therapy and expiration date for medical exception.

ii. The prescriber shall provide information requested on the MNF 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, HBID number, service description, service date and prior authorization number, if approved, the length of the approval and the appeals process if the pharmacist or prescriber 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- 9.14, Provisions for appeals; 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 § 10:58A-2.5

New Rule, R.1999 d.232, effective 7/19/1999 (operative September 1, 1999).
See: 31 N.J.R. 245(a), 31 N.J.R. 1956(a).
Former N.J.A.C. 10:58A-2.5, Clinical laboratory services, recodified to N.J.A.C. 10:58A-2.6.
Amended by R.2000 d.265, effective 7/3/2000.
See: 32 N.J.R. 1127(a), 32 N.J.R. 2483(a).
In (d), substituted references to Medicaid Eligibility identification numbers for references to HSP identification numbers throughout, and inserted a reference to prescribers in 3.
Amended by R.2011 d.119, effective 4/18/2011.
See: 42 N.J.R. 2890(a), 43 N.J.R. 1015(a).
Rewrote (a); in (b), substituted "MEP" for "medical exception process (MEP)"; in (c) and in the introductory paragraph of (d), substituted "MEP" for "medical exception process"; in (c), substituted "NJ DURB" for "New Jersey DUR Board"; in the introductory paragraph of (d)1, substituted "that" for "which"; in (d)1i, substituted "Medical Necessity Form (MNF)" for "Prescriber Notification Letter" and "Health Benefits Identification (HBID)" for "Medicaid Eligibility identification" and "and" for a comma following "quantity", and deleted a comma following "therapy"; in (d)1ii, substituted "MNF" for "Prescriber Notification"; and in (d)3, substituted "HBID" for "mailing address, Medicaid Eligibility identification", and deleted "the reviewer" following the first occurrence of "number" and a comma following "date".

Amended by 56 N.J.R. 2191(a), effective 11/4/2024