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OptumRx MAC Appeal Submission Guide and FAQ

 

Note: See state specific additional requirements below for Alaska, Arkansas, Kansas, Louisiana, New Mexico, Oregon, and Washington.


Appeals must be submitted within 30 days of the claim fill date or within such time period as may be required by applicable state law. Appeals exceeding the allowable submission period will NOT be reviewed. Please refer back to the pharmacy manual for information specific to your state. 

Please submit all MAC Appeal requests using the approved OptumRx spreadsheet via the Pharmacy Portal using your OptumID. If you do not have an OptumID you may register to create one here:


Create OptumID Here

Any other form of appeal submission will not be accepted for review. Excel file for Appeals can be found here:

MAC Appeal Form

MAC Appeal Detail must be filled out completely unless noted as "Optional".  Submissions with missing information will be invalid and excluded from review.

All reviews of any individual claim from a pharmacy are final and will NOT be reviewed again.

Alternate and/or reference National Drug Code information provided on denied appeal responses, where applicable and required by law, represent products identified by OptumRx as being available from a national wholesaler operating in your state at or below the maximum allowable cost as determined by OptumRx. 

OptumRx MAC review process does not provide clinical advice nor direction for product substitutions.  Please refer to your state substitution laws.


Required Information

The following fields must be filled out in order to be processed:
         -Filled Date
         -BIN
         -PCN
         -NCPDP
         -RX #
         -NDC
         -Compound
         -Reason for Appeal

**NEW** State specific requirements per State MAC Legislation

  • Alaska Providers

In accordance with State of Alaska House Bill 240, effective July 1, 2019, where applicable, Alaska providers are required to include the provider’s drug acquisition cost* information with their appeal submission from two of its contracted suppliers as outlined below.  Please enter information into columns “K” and “L” of the OptumRx MAC Appeal Submission Template.

If the required drug acquisition cost information is not submitted at time of appeal, OptumRx will be unable to review and resolve the MAC Appeal, and will request resubmission of the MAC Appeal with the required information for reprocessing.

  • Arkansas Providers

Consistent with Ark. Code. Ann. § 17-92-507, where applicable, Arkansas providers are required to include pharmacy acquisition cost* with their appeal submission as outlined below. Please enter information into column “K” of the OptumRx MAC Appeal Submission Template.

If the required pharmacy acquisition cost information is not submitted at time of appeal, OptumRx will be unable to review and resolve the appeal and will request resubmission of the appeal with the required information for reprocessing.

This is in accordance with Arkansas Insurance Department Bulletin NO. 5-2022, effective June 1, 2022, requiring PBMs allow providers to transmit their invoice cost information with their appeal submission.  Providers can submit their invoice via email to MAC@Optum.com. Providers are required to submit with the following information;
Email Subject Line: File name and submission date of the appeal.
Body of the email: Rx number, fill date, and the NDC number.

  • Kansas Providers

In accordance with State of Kansas Senate Bill 28, effective July 1, 2022, where applicable, Kansas Providers have the option to include their total reimbursement amount* information with their appeal submission from its contracted supplier as outlined below.  Please enter information into column “N” of the OptumRx MAC Appeal Submission Template.

  • Louisiana Providers

In accordance with State of Louisiana Senate Bill 41, effective July 1, 2020, where applicable, Louisiana providers may submit a request for a secondary review of a previously denied MAC appeal when the provider is unable to acquire the OptumRx referenced product from the OptumRx referenced Wholesaler at or below MAC.  In order to request a secondary review, provider will need to use the MAC appeal form and select “Louisiana - Wholesaler unavailability” under the “Reason for Review” column indicating you are unable to acquire the referenced product from the referenced wholesaler on the originally denied appeal. You will also be required to include your drug acquisition cost* information as outlined below. Please enter your drug acquisition cost information into column “K” of the OptumRx MAC Appeal Submission Template. If the drug acquisition cost information and “Louisiana – Wholesaler unavailability” reason code are not submitted at the time of your secondary review request, OptumRx will not have the necessary information to conduct a secondary review.  The allowable period for a secondary review request is 14 business days following our initial denial.

  • Mississippi Providers

In accordance with State of Mississippi House Bill 708, effective January 01, 2021, where applicable, Mississippi providers are required to include the provider’s drug acquisition cost* information with their appeal submission from its contracted supplier as outlined below.  Please enter information into column “K” of the OptumRx MAC Appeal Submission Template.

If the required drug acquisition cost information is not submitted at time of appeal, OptumRx will be unable to review and resolve the MAC Appeal, and will request resubmission of the MAC Appeal with the required information for reprocessing.

Mississippi providers may submit a request for a secondary review of a previously denied MAC appeal when the provider is unable to acquire the OptumRx referenced product from the OptumRx referenced Wholesaler at or below MAC.  In order to request a secondary review, provider will need to use the MAC appeal form and select “Mississippi - Wholesaler unavailability” under the “Reason for Review” column indicating you are unable to acquire the referenced product from the referenced wholesaler on the originally denied appeal. You will also be required to include your drug acquisition cost* information as outlined below. Please enter your drug acquisition cost information into column “K” of the OptumRx MAC Appeal Submission Template. If the drug acquisition cost information and “Mississippi – Wholesaler unavailability” reason code are not submitted at the time of your secondary review request, OptumRx will not have the necessary information to conduct a secondary review.  The allowable period for a secondary review request is 30 business days following our initial denial.

  • New Mexico Providers

In accordance with New Mexico Legislation NMAC 13.10.30, effective March 1, 2022, where applicable, New Mexico Providers are now required to include their Net Purchase Price of Drug (column M), Total Reimbursement (column N), Drug Name (column O), and Drug Strength (column P). In order to ensure prompt and accurate review of your appeal this information must be provided on the MAC appeal form at time of submission.

  • Oregon

In accordance with State of Oregon Legislation 45414, effective January 01, 2021, where applicable, Oregon providers can now provide cost information based on generally available for purchase products.  In order to review, provider will need to use the MAC appeal form and select “Oregon Pharmacy – Unable to acquire product at or below specified amount for 3 month or less supply” under the “Reason for Review” column. When selecting this reason code, the pharmacy must submit the provider’s drug acquisition cost* information with their appeal submission from its contracted supplier as outlined below.  Please enter information into column “K” of the OptumRx MAC Appeal Submission Template.

If the required drug acquisition cost information is not submitted at time of appeal, OptumRx will be unable to review and resolve the MAC Appeal, and will request resubmission of the MAC Appeal with the required information for reprocessing.

  • Washington Providers

Washington providers are required to include the provider’s drug acquisition cost* information with their appeal submission from its contracted supplier as outlined below.  Please enter information into column “K” of the OptumRx MAC Appeal Submission Template.

If the required drug acquisition cost information is not submitted at time of appeal, OptumRx will be unable to review and resolve the MAC Appeal, and will request resubmission of the MAC Appeal with the required information for reprocessing.

*Submitted provider drug acquisition cost information must be the Provider’s lowest per unit acquisition cost for the drug dispensed on the appealed claim during the time period of the claim.  The per unit drug acquisition cost you provide must be net of any rebates and discounts from your supplier or the manufacturer and must be limited to the drug ingredient cost, excluding any pharmacy service fees.  OptumRx reserves the right to request supporting documentation, including, but not limited to, supplier and manufacturer invoices.  Drug acquisition cost and related information submitted to OptumRx is subject to audit and validation.

Additional available fields on the MAC Appeal Submission Form not listed above are optional.


Formatting

Any formatting errors will cause the entire file to be sent back for corrections and resubmission.  Please follow the specifications in the headings so your appeals can be processed as quickly as possible. 

Following Fields must reflect information from the Drop-down Menu as follows:
     Reason for Review
         -MAC Unit is below cost
         -Drug is experiencing supply issues, please review MAC.
         -Dispensed least expensive generic
         -Other – Please use the notes section to explain
     Compound Y/N
         -Y (select Y to indicate a compound)
         -N (select N to indicate  a non-compound)
         -If more than one ingredient is to be reviewed fill out individual lines for each NDC.


Common Formatting Errors

  • Not including leading zeros in BIN, NCPDP, RX#, PCN, or NDC (example NCPDP 412345 instead of 0412345).
  • Incorrect or missing date of fill (example 3/10/2103 instead of 3/10/2013).
  • Changing the format to custom to give the appearance of leading zeros.  Numbers must be in text format to be processed.
  • Missing any of the required fields.
  • Adding letters to BIN numbers (example 012353A instead of 012353).
  • Entering NDC with dashes (example 00012-3456-78 instead of 00012345678). 
  • If you have any questions regarding this process or any concerns, please let us know so we can address them.  Please refer to the Pharmacy Manual for contact information.  
  • Any resolved appeals returned with the status of:
  • Client MAC CIG, are considered to be custom MAC lists maintained by Cigna through their direct contract with pharmacies.  Any questions regarding the Cigna Client MAC pricing claims should be addressed to MACInquiry@cigna.com.
  • For all Georgia Medicaid MAC appeals submitted, please refer online under www.mmis.georgia.gov → Pharmacy → Pricing List for a complete list of GMAC prices, including changes
  • Any resolved appeals with the status of Claim Paid according to the effective rate contracted, implies that the claim paid according to the Effective Rate contracting, providing increased pricing transparency and predictability of rate trends. Guarantees offer PSAO with guardrails to protect the financial interest of its affiliated pharmacies while ensuring access to OptumRx networks.

Resolution Responses and definitions: 

Appeal Reason Description  Definitions Status 
Approved Pricing Reconciliation OptumRx has reviewed and approved appeal. Payment will be issued for amount due as a result of adjusted reimbursement. (R&R not required) Approved 
Acq not Provided ACQ cost needs to be submitted  Denied
Appeal window exceeded Appeal exceeds allowable submission period Denied
AWP Claim paid at the contracted AWP rate Denied
Claim not found Claim could not be found within Optum given the supplied criteria. Denied
Claim Not Found - Unknown RxNumber Claim could not be found within Optum given the supplied criteria. Denied
Claim Paid according to effective rate contracted Claim Paid at the Contracted Rate Denied
Claim Paid at Provider submitted U & C Claim Paid at Submitted Usual and Customary cost Denied
Client MAC Contact client to review claim Denied
Duplicate/Duplicate Appeal  Duplicate Appeal Submission Denied
FUL Claim Paid at Federal Upper Limit Denied
No change Appeal denied. MAC price accurate Denied
No Change MAC Price Valid Appeal denied. MAC price accurate Denied
Non Paid Claim Rejected / X (Reversed) /Claim Reversed. Appeal as submitted is for a reversed or rejected claim. Can only appeal paid claims. Denied
Non-MAC claim Claim could not be found within Optum given the supplied criteria. Denied
Non-OptumRx claim Claim could not be found within Optum given the supplied criteria. Denied
Non-paid claim Rejected / X (Reversed) /Claim Reversed. Appeal as submitted is for a reversed or rejected claim. Can only appeal paid claims. Denied
Not Found Claim could not be found within Optum given the supplied criteria. Denied
Paid at AAC Claim paid at the contracted AAC rate Denied
Paid at AWP/WAC Claim paid at the contracted AWP rate/paid at WAC pricing  Denied
Paid at Contracted Rate Claim Paid at the Contracted Rate Denied
Paid at FUL Claim Paid at Federal Upper Limit Denied
Paid at NADAC Claim paid at NADAC pricing Denied
Paid at pharmacy submitted Claim Paid at Submitted Usual and Customary cost Denied
Paid at SD Claim Paid at Submitted Usual and Customary cost Denied
Paid at SM Claim Paid at the Contracted Rate Denied
Paid at U&C Claim Paid at Submitted Usual and Customary cost Denied
Paid at WAC Claim paid at WAC pricing Denied
Paid at zero Non MAC Claim Denied
Pending Review Appeal is under review  Denied
Previous Change MAC price increased Denied
Provider Reimbursed >= Provided Submitted No Change  Denied
Too Old Appeal exceeds allowable submission period Denied
Unknown BIN Claim could not be found within Optum given the supplied criteria. Denied
Unknown Date of Service Claim could not be found within Optum given the supplied criteria. Denied
Unknown NCDPDId Claim could not be found within Optum given the supplied criteria. Denied
Unknown NDC Claim could not be found within Optum given the supplied criteria. Denied
Unknown RxNumber Claim could not be found within Optum given the supplied criteria. Denied
WAC Claim paid at WAC pricing Denied