New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 4 - PHARMACY SERVICES, PRESCRIBING, AND PRACTITIONER ADMINISTERED DRUG ITEMS › Section 8.324.4.15 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
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.