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10.15.2016 Types of pharmacy point of service claims included in UM 4, Element H file review What types of pharmacy point of service claims should be included in the scope of UM 4, Element H (UM 4, Element F in MBHO and UM-CR)?

The following denials (rejections) are included in the scope of UM 4, Element H (UM 4, Element F in MBHO and UM-CR):

  • Claims for prescriptions that were refilled too soon.
  • Claims for prescriptions with the incorrect dosage or quantity.*
  • Claims that were denied because the organization’s reasonable filing procedures were not followed (e.g., lack of prior authorization).

* Inaccurately filed claims that were rejected because of incorrect dosage or quantity may be considered pending until a decision is made. If the request is denied, the claim is included in the scope of UM 4, Element H.

ALL 2016