MedicaidPrior AuthHigh impact
Newsletter Vol. 9, No. 67
New Jersey Medicaid·NJ · Pharmacy·Provider Notice
Effective date
Dec 1, 1999
We identified it
Jun 20, 2026
Summary
New Jersey implemented a Medical Exception Process (MEP) for prescription drug claims that exceed Drug Utilization Review (DUR) standards across Medicaid, NJ KidCare, GA, PAAD, ADDP, and CF programs. Pharmacists must contact First Health Services Corporation to request prior authorization for drugs flagged by 12 specific DUR edits, with most claims allowed an initial 30-day supply during the authorization review period. Claims without approved PA numbers will be denied after the 30-day extension expires.
Action Required
By December 1, 1999: Pharmacy and prescriber staff must implement MEP procedures. (1) Pharmacists must monitor POS system for edits 403, 404, 405, 535, 538, 916, 917, 921, 922, 927, 928, and 929 on pharmacy claims. (2) When edit 927 posts, pharmacist must immediately contact First Health Services Corporation at 1-877-888-2939 to initiate MEP; POS will auto-allow 30-day supply. (3) When edit 929 posts, pharmacist must contact FH to request PA; claims are automatically denied without PA number. (4) Pharmacists must provide beneficiary name, ID number, prescriber name/address/phone/PSN, NDC, service date, metric quantity, days supply, and ICN when requesting PA. (5) Prescribers must respond promptly to FH requests for medical justification during the 30-day extension period to obtain PA before authorization expires. (6) Update internal workflows to track PA numbers and ensure claims are resubmitted with authorization within 1 hour of PA issuance (non-emergency requests before 5:00 P.M.). Consequences: Claims exceeding DUR standards will be denied without PA authorization; beneficiary medication access will be interrupted if PA is not obtained during the 30-day extension period.