MedicaidPrior AuthHigh impact
Newsletter Vol. 22, No.12
New Jersey Medicaid·NJ · Pharmacy, Geriatrics, Palliative Care·Provider Notice
Effective date
Jul 10, 2012
We identified it
Jun 20, 2026
Summary
New Jersey expanded its Medical Exception Process (MEP) to include 11 additional Drug Utilization Review (DUR) standards for long-term care facilities and assisted living residences. Pharmacists must now obtain prior authorization from Molina Medicaid Solutions before dispensing medications that trigger these new DUR error codes, or risk claim denials. This affects prescription claims for FamilyCare/Medicaid and PAAD beneficiaries in LTC settings.
Action Required
By July 10, 2012: Pharmacy providers and LTC facilities in New Jersey must implement new prior authorization workflows. Specific actions: (1) Train pharmacy staff to recognize the 11 new DUR error codes (0403, 0404, 0405, 0447, 0535, 0537, 0869, 2007, 2100, 2111, 0830) returned by the POS claims system; (2) Establish protocol to contact Molina Medicaid Solutions at 1-877-888-2939 (8 AM–5 PM) or 1-866-378-8251 (after-hours emergency) before dispensing when these codes appear; (3) Update billing software to flag claims with these error codes and require MEP prior authorization completion before submission; (4) Ensure LTC pharmacy providers report the 7-digit Medicaid Provider Number and Facility Name in NCPDP fields 336-8C and 385-3Q; (5) Document that emergency supplies (up to 6 days) may be dispensed without prior auth only if MEP On-Call Service is unavailable, except for severe drug-drug interactions; (6) Communicate to all prescribers that PAAD beneficiaries cannot receive emergency supplies without prior auth payment. Failure to obtain prior authorization before dispensing will result in claim denials and potential patient harm.