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.
HP 2016