All MAD services are subject to utilization review for
medical necessity and program compliance. Reviews can be performed before
services are furnished, after services are furnished and, before payment is
made or after payment is made; see 8.302.5 NMAC. Once enrolled, providers
receive directions on how to access instructions and documentation forms
necessary for prior authorization and claims processing. Review or prior
authorization may be required for items for which a less expensive or
therapeutically preferred alternative should be used first. In addition to the
generic-first coverage provisions, applicable therapeutic "step" requirements
will be based on published clinical practice guidelines, professional standards
of health care and economic considerations.
A.
Prior authorization: MAD or
its designee reviews all requests for prior authorizations. Services for which
prior authorization was obtained remain subject to utilization review at any
point in the payment process.
B.
Eligibility determination: Prior authorization of services does
not guarantee that an individual is eligible for MAD services. Providers must
verify that an individual is eligible for MAD services at the time services are
furnished and determine if the MAP eligible recipient has other health
insurance.
C.
Reconsideration: Providers who disagree with prior authorization
request denials or other review decisions can request reconsideration; see
8.350.2 NMAC.
D.
Drug
utilization review: The MAD drug utilization review (DUR) program is
designed to assess the proper utilization, quality, therapy, medical
appropriateness and costs of prescribed medication through evaluation of claims
data, as required by 42 CFR
456.700-716. The DUR program is done on a
retrospective, prospective and concurrent basis. This program shall include,
but is not limited to, data gathering and analysis and a mix of educational
interventions related to over-utilization, under-utilization, therapeutic
duplication, drug-to-disease and drug-to-drug interactions, incorrect drug
dosage or duration of treatment and clinical abuse or misuse. Information
collected in the DUR program that identifies individuals is confidential and
may not be disclosed by the MAD DUR board to any persons other than those
identified as the MAP eligible recipient's service providers or governmental
entities legally authorized to receive such information.
(1)
Prospective drug use review:
Prospective DUR (ProDUR) is the screening for potential drug therapy problems
(such as, over-utilization, under-utilization, incorrect drug dosage,
therapeutic duplication, drug-disease contraindication, adverse interaction,
incorrect duration of drug therapy, drug-allergy interactions,
clinical abuse or misuse) before each prescription is dispensed. The dispensing
pharmacist is required to perform prospective drug use review prior to
dispensing. Only a licensed pharmacist or intern may perform ProDUR activities.
The pharmacist may be required to insert appropriate DUR override codes when
the ProDUR system detects drug therapy issues. In retrospective review of paid
claims, payment may be recouped for claims in which the pharmacist has not
followed accepted standards of professional practice.
(2)
Counseling: Pursuant to
42 CFR
456.705, each dispensing pharmacist must
offer to counsel each MAP eligible recipient or his or her authorized
representative receiving services who presents a new prescription, unless the
MAP eligible recipient or his or her authorized representative refuses such
counsel. Pharmacists must document these refusals. If no documentation of
refusal of counseling is available or readily retrievable, it will be assumed
that appropriate counseling and prospective drug use review has taken place. A
reasonable effort must be made to record and maintain the pharmacist's comments
relevant to said counseling and prospective drug review, particularly when
ProDUR overrides are performed. Counseling must be done in person, whenever
practicable. If it is not practicable to counsel in person, providers whose
primary patient population does not have access to a local measured telephone
service must provide a MAP eligible recipient access to a toll-free
number.
