Programs: Maryland Medical Assistance Program (MA)

Max Days 120

Max Days 180

Claims that deny for exceeding the max day limit will return edit 76 (plan limitations exceeded) and the message text: Max Daily Limit Exceeded/For PA, call DHMH at 1-410-767-1755

Requests to override Days Supply are directed to Maryland OOEP at (410) 767-1755.

Providers will have the ability to override Days Supply Limits and/or PA Required conditions by entering a value of ‘5’ (exemption from prescription limits) in the Prior Auth Type Code field (NCPDP field # 416-DG). Note:

1. 
   This override situation applies to TPL processing only
   
2. 
   A value of 5 in the Prior Auth Type Code field is valid only if Other Coverage Code = 2 (other coverage exists-payment collected)
   
3. 
   A value of 8 in the Prior Auth Type Code field is valid only if recipient is pregnant (this will override both coverage limitations and copay)
   

There are four methods a provider can receive a Prior Authorization for Maryland (OOEP) Medicaid recipients:

• 
  ACS Technical Call Center
  
• 
  Maryland Medicaid Staff
  
• 
  CAMP office
  
• 
  SmartPA
  

• 
  PA denials will be handled by ACS and will return the following message text in the response: “Prior Authorization Required, Call ACS at 1-800-932-3918 (24/7/365)”.
  
• 
  PA denials handled by the State will return the following message text in the response:
  ”Prior Authorization Required, Call MD/ MCOA at (410) 767-1755, M-F, 8:30 am – 4:30 pm”.
  
• 
  ACS will ensure that PA denials handled by the State's CAMP Office will return the following message text in the response: “Prior Authorization Required, call CAMP Office, (410) 706-3431”.
  

All Days Supply

Growth Hormones

Synagis (Palivizumab)

Female Hormones for a male and vice versa

Nutritional supplements (see MD PA form for clinical criteria)

Recipient Lock-In

Price (long-term PAs only)

Oxycontin Quantity (during business hours)

Antihemophilic Drugs (claim pended in X2 and evaluated manually by State) -Duragesic Patch Quantity (during business hours)

Topical Vitamin A Derivatives

Opiate Agonists for Hospice and Hospice/LTC

Antiemetic

Serostim

Orfadin

Revatio

Quantity (Note Oxycontin, Duragesic Patch exceptions)

1. 
   CNS Stimulants
   
2. 
   Actiq
   
3. 
   Anti-Migraine
   
4. 
   Anti-Psychotics
   
5. 
   Oxycontin, Duragesic Patch Qty for after hours/weekends
   

1. 
   Depo Provera
   
2. 
   Lupron Depot
   

1. 
   PDL - Non-Preferred drugs
   

2. 
   Early Refill
   
3. 
   Maximum dollar limit per claim = $2500.
   
4. 
   Age Restrictions – Administered by X2
   
5. 
   Max Quantity overrides – Administered via X2
   

SmartPA is an automated, rules engine, driven system that uses both the medical and pharmacy information to either grant a Prior Authorization or deny based on the rules for that particular drug being dispensed. If criteria are met upon claims submission, no call for PA will be required. The system will automatically generate a Prior Authorization and the claim will pay. When a claim is denied by SmartPA, the exception message will state which criteria was not met in order for the PA to be issued. The ACS Technical Call Center will handle any Prior Authorization questions based on a SmartPA denial. Below is a list of drugs / categories that will be handled by SmartPA:

1. 
   CNS Stimulants
   
2. 
   Actiq
   
3. 
   Anti-Migraine
   
4. 
   Atypical Antipsychotics
   
5. 
   Serostim
   
6. 
   Botox
   
7. 
   Synagis
   
8. 
   Growth Hormones
   
9. 
   Antiemetics
   
10. 
    Topical Vitamin A
    
11. 
    Orfadin
    
12. 
    Revlamid
    
13. 
    Revatio
    
14. 
    Nutritional Supplements
    
15. 
    Oxycodone
    

Coordinated ProDur / Mental Health Formulary

Coordinated ProDUR:
Coordinated ProDUR (CPD) provides a mechanism to link all of a recipient’s pharmacy history, regardless of payer, for purposes of performing ProDUR. This includes all:
MCO Services

Specialty Mental Health Services

Medical Assistance Program Services

Providers will submit a single transmission only.

Coordinated ProDUR editing is “message only” (i.e. no denials).
The ACS POS system has a mechanism, which at the pharmacy level, with one transmission, will electronically link the payer with all recipient drug information necessary to perform Coordinated PRO-DUR. This requires any payer (MCO or MA) to have available at the time of adjudication all recipient drug history including but not limited to somatic, psychotropic, and specified HIV drug paid claims information to perform a comprehensive PRO-DUR, eliminating the need for the pharmacy provider to make multiple entries into different networks. Regardless of the final payer, only one transmission fee, which includes switching cost, is to be paid by pharmacy providers adjudicating claims through this program.
ACS will process claims for the Mental Health Carve-out drugs then send any drug that are denied to the MCO for processing. All claims MUST be sent to the following:
PCN:

BIN: 610084

Group ID’s
I will get these and insert them then resend.