(OHWORK) BILL SUBJECT TO SMARTPA CLINICAL RULES. INJURED WORKER DOES NOT HAVE REQUIRED DIAGNOSIS ON FILE SUPPORTING THE USE OF THE DRUG.
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4822
|
|
out of state provider req. PA
(OHWORK) BILL SUBJECT TO SMARTPA CLINICAL RULES. INJURED WORKER DOES NOT HAVE REQUIRED DIAGNOSIS ON FILE SUPPORTING THE USE OF THE DRUG.
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4914
|
B
|
Client Specific (IN) Non-PDL Drug - Prior Authorization Required (TCP Program)
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4140
|
B
|
If the (Custom Plan Max Units Accum is not equal to “N” (None)
OR
The Custom Plan Max Units is not equal to Work Default Max Units (99999.999))
AND
The Custom Plan Max Units Accum equals “C” (Acute Dose Only)
AND
The Custom Plan Maintenance Claim Dose less than Work Default Dose (9999.999)
AND
The Daily Dose (derived by taking Claim Submitted Quantity / Claim Days Supply) greater than Custom Plan Maintenance Claim Dose
AND
The Claim Submitted Quantity is greater than Custom Plan Max Units
AND
The Custom Plan Max Units Status equals “P” (PA Required)
AND
The prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4141
|
B
|
If the Custom Plan Max Units Accum equals “A” (All Doses)
AND
The Claim Submitted Quantity is greater than Custom Plan Max Units
AND
The Custom Plan Max Units Status equals “P” (PA Required)
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4142
|
B
|
If the Custom Plan Max Number of Refills is not equal to “Unlimited” (999)
AND
The Plan Benefit Limit Override PA equals “I” (Override Initial RX)
AND
The Claim Refill Indicator greater 0
AND
The Custom Plan Max Number of Refills less than (<) The Claim Refill Indicator
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4143
|
B
|
The Plan Benefit Limits indicate “Not Covered”
AND
The Claim PA Type Code not = ‘8’ (PA Override)
AND
The Plan Benefit Limit Override PA equals “I” (Override Initial RX)
AND
The Claim Refill Indicator is equal to 0
AND
The Plan Benefit Limt Med Cert Indicator = ‘Y’ (Override)
AND
The Claim PA Indicator not = “Prior Authorized” or “Covered”)
AND
(The Claim PA Type Code = ‘2’ (Med Cert)
OR
The Claim RX Override Code = ‘7’ (Medically Necessary)).
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4144
|
B
|
If the Custom Plan Max Number of Refills is not equal to “Unlimited” (999)
AND
The Plan Benefit Limit Override PA equals “Y” (Override)
AND
The Custom Plan Max Number of Refills less than Claim Refill Indicator
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4145
|
B
|
The Plan Benefit Limit Override PA equals “Y” (Override) and the Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4145
|
B
|
Client is in Nursing Home, please try Medicare part D
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4145
|
B
|
Client is in Nursing Home
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4148
|
C
|
Client Specific Edit (MA): PA Required For Telephone Prescription Schedule II Drug
(also checks for oxycontin limits exceeded))
If the prescription originated by telephone for a schedule II drug
AND
It is not an emergency service level
AND
It is not a paper claim
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4149
|
B
|
If the Daily Dose (derived by taking Claim Submitted Quantity / Claim Days Supply) greater than Custom Plan Maintenance Claim Dose
AND
The Custom Plan Maintenance Indicator equals “Pay”
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4150
|
B
|
If the Custom Plan Maximum Daily Dose Units is not equal to 0
AND
The Daily Dose (derived by taking Claim Submitted Quantity / Claim Days Supply) greater than Custom Plan Maximum Daily Dose
AND
Claim dose indicator equals ‘pay’
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4151
|
B
|
If the Custom Plan Minimum Daily Dose Units is not equal to 0
AND
The Daily Dose (derived by taking Claim Submitted Quantity / Claim Days Supply) is less than the Custom Plan Minimum Daily Dose
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4152
|
B
|
The Claim Participant Age is not less than the Custom Plan Drug Maximum Age
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”)
AND
The Custom Plan Age Edit Status equals “PA Required”
AND
The Claim’s Prior Authorization Type Code not = “PA Override” (‘8’).
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4153
|
B
|
If the Claim Participant Age is not greater than the Custom Plan Drug Minimum Age
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”)
AND
The Custom Plan Age Edit Status equals “PA Required”
AND
The Claim’s Prior Authorization Type Code not = “PA Override” (‘8’).
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4154
|
B
|
The (Custom Plan Days Supplied Accum is not equal to “N” (None)
AND
The Custom Plan Days Supplied is not equal to Work Default Days (999))
AND
The Custom Plan Days Supplied Accum equals “C” (Acute Dose Only)
AND
The Custom Plan Maintenance Claim Dose less than the Work Default Dose (9999.999)
AND
The Daily Dose (derived by taking Claim Submitted Quantity / Claim Days Supply) is greater than the Custom Plan Maintenance Claim Dose
AND
The Claim Submitted Days is greater than Custom Plan Days Supplied
AND
The Custom Plan Days Supplied Status equals “P” (PA Required)
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4155
|
B
|
If the Custom Plan Days Supplied Accum equals “A” (All Doses)
AND
The Claim Submitted Days is greater than the Custom Plan Days Supplied
AND
The Custom Plan Days Supplied Status equals “P” (PA Required)
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4156
|
B
|
An entry on the Custom Record exists
AND
The DUR Units Accumulator Code on the Custom Record is not equal to “N”
AND
The DUR Units Amount on the Custom Record is greater than +0.000 and less than +99999.999
AND
((The DUR Units Accumulator Code on the Custom Record equals “C” (Acute))
AND
(IP Daily Dose is greater than the Maintenance Claim Dose on the Custom Record)
AND
(DUR Units Total is greater than the DUR Units Amount on the Custom Record)
AND
(DUR Units Status on the Custom Record equals “P”)
AND
(Prior authorization indicator is not equal to “C” (Covered) and not equal to “A” (Prior Authorization))
OR
((DUR Units Accumulator Code on the Custom Record equals “A” (All))
AND
(DUR Units Total is greater than the DUR Units Amount on the Custom Record)
AND
(DUR Units Status on the Custom Record equals “P”)
AND
(Prior authorization indicator not equal to “C” (Covered) and not equal to “A” (Prior Authorization)))
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4157
|
B
|
An entry exists on the Custom Record
AND
DUR Days Supply Accumulator Code on the Custom Record is not equal to “N”
AND
DUR Days Supply Amount on the Custom Record is greater than +0 and less than +999
AND
((DUR Days Supply Accumulator Code on the Custom Record equals “C” (Acute))
AND
(IP Daily Dose is greater than the Maintenance Claim Dose on the Custom Record)
AND
(DUR Days Supply Total is greater than the DUR Days Supply Amount on the Custom Record)
AND
(DUR Days Supply Status on the Custom Record equals “P”)
AND
(Prior authorization indicator is not equal to “C” (Covered) and not equal to “A” (Prior Authorization)))
OR
((DUR Days Supply Accumulator Code on the Custom Record equals “A” (All))
AND
(DUR Days Supply Total is greater than the DUR Days Supply Amount on the Custom Record )
AND
(DUR Days Supply Status on the Custom Record equals “P”)
AND
(Prior authorization indicator is not equal to “C” (Covered) and not equal to “A” (Prior Authorization)))
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4158
|
B
|
An entry exists on the Custom Record
AND
DUR Max RX Accumulator Code on the Custom Record is not equal to “N”
AND
DUR Max RX Amount on the Custom Record is greater than +0 and less than +999
AND
((DUR Max RX Accumulator Code on the Custom Record equals “C” (Acute))
AND
(IP Daily Dose is greater than the Maintenance Claim Dose on the Custom Record)
AND
(DUR Max RX Total is greater than the DUR Max RX Amount on the Custom Record)
AND
(DUR Max RX Status on the Custom Record equals “P”)
AND
(Prior authorization indicator is not equal to “C” (Covered) and not equal to “A” (Prior Authorization)))
OR
((DUR Max RX Accumulator Code on the Custom Record equals “A” (All))
AND
(DUR Max RX Total is greater than the DUR Max RX Amount on the Custom Record)
AND
(DUR Max RX Status on the Custom Record equal to “P”)
AND
(Prior authorization indicator is not equal to “C” (Covered) and not equal to “A” (Prior Authorization)))
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4159
|
C
|
Exceeds Min or Max Age Limit
The Participant Age is equal to or greater than the Maximum Age or less than the Minimum Age allowed
Original Mass Edit Text:
Exceeds Min or Max Age Limit
The Customer ID is equal to Massachusetts and a Custom Record Exists for the Customer ID
AND (The IP Participant Age is equal to or greater than the Maximum Age on the Custom Record)
OR (IP Participant Age is less than the Minimum Age on the Custom Record)
AND The Prior authorization indicator not equal to “Covered”
AND The Age Edit Status on the Custom Record equals “Prior Authorization”.
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4381
|
B
|
Formulary exists for the Plan and Drug Code
AND
Plan Detail Formulary Type Code = ‘C’ (Closed)
AND
Formulary Coverage Indicator not = ‘N’ (Not Covered)
AND
Claim’s Prior Authorization Indicator = ‘ ‘ (No PA) - ‘P’ (Use Plan) - or ‘R’ (PA doesn’t match claim)
AND
Claim’s DAW Code not = ‘1’ (Physician)
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4447
|
B
|
The In process Billing Provider ID not equal History Billing Provider ID
AND
First date of service on the current claim must be after the first date of service on the history claim.
AND
First date of service on the current claim must be before the date calculated to be the history claim’s first date of service plus days supplied less the grace period.
AND
The claim dates of service overlap
AND
(History Route Code equals IP Route Code
OR
(IP Route Code equals (A or B or C or H or L or S or T or 1 or 2 or 3 or 7)
AND
History Rout Code equals (A or B or C or H or L or S or T or 1 or 2 or 3 or 7))
AND
The History NDC found on Drug Record
AND NOT
(History Generic Code equals IP Generic Code
OR
History NDC equals IP NDC
OR
IP Generic Code equals “01697” AND History Generic Code equals “02521”
OR
History NDC equals IP NDC
OR
IP Generic Code equals “01698” AND History Generic Code equals “02529”
OR
History NDC equals IP NDC
OR
IP Generic Code equals “92989” AND History Generic Code equals “08453”
OR
IP Generic Code equals “04348” AND History Generic Code equals “08450”
OR
IP Generic Code equals “92999” AND History Generic Code equals “08452”)
AND
The route codes must be the same or they must both be systemic route
(History Route Code equals IP Route Code
OR
(IP Route Code equals (A or B or C or H or L or S or T or 1 or 2 or 3 or 7)
AND
History Rout Code equals (A or B or C or H or L or S or T or 1 or 2 or 3 or 7)))
AND
Specific therapeutic class must be the same. Any Therapeutic Class Code Specific on the Drug Record from the IP NDC is equal to any Therapeutic Class Code specific on the Drug Record from the History NDC.
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4448
|
C
|
Drug to Drug Interaction
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4449
|
B
|
If Medical Profile Override Indicator set to NO
and
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
The Dose Form on the Drug Record from the IP NDC must equal ‘Each’ or ‘Milliliter’
AND
Calculated Daily Dose must be more than the Maximum Daily Dose on the Drug Record
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4125
|
B
|
StepCare
If the customer participates in StepCare
AND
The drug is not covered by the Plan or by a PA
AND
The reject code on the StepCare record is “75”
AND
The number of agents taken is less than the number of agents required
OR
The amount of time the drugs were taken was less than the therapy span required.
OR
If the number of agents required is greater than the number of drugs that were each taken for the correct therapy span
|
B
|
D
|
B
|
B
|
|
|
|
76
|
Plan Limitations Exceeded
|
4675
|
FL
|
Claim subject to SmartPA Clinical Rules. Patient has another medication in history which indicates duplication of therapy.
|
