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OptumRx MAC Appeal Submission Guide and FAQ

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

https://campaign.optum.com/content/dam/optum/resources/Downloads/orx_mac_appealsubmissiontemplate_pharmacy.xlsx

Please submit all Appeals to MAC@optum.com. Submit a claim only once, duplicate claims will NOT be reviewed.  

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.

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. 

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

  • Extra fields are provided and are optional to complete.

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 affliated pharmacies while ensuring access to Optumx networks.

                                 

Resolution Responses and definitions: 

Action: Definitions:

Increase

MAC price increased

OK

Appeal denied. MAC price accurate

Non-CTRx

Claim could not be found within Optum given the supplied criteria.

Non-OPTRx

Claim could not be found within Optum given the supplied criteria.

Duplicate Appeal

Duplicate Appeal Submission

Not found

Claim could not be found within Optum given the supplied criteria.

FFUL

Claim Paid at Federal Upper Limit

FUL

Claim Paid at Federal Upper Limit

HCFA

Claim Paid at CMS pricing

No Change

Appeal denied. MAC price accurate

Previous Change

MAC price increased

Non Paid Claim

Rejected / X (Reversed) /Claim Reversed. Appeal as submitted is for a reversed or rejected claim. Can only appeal paid claims.

Submitted/SD

Claim Paid at Submitted Usual and Customary cost

Too Old

Appeal exceeds allowable submission period

U&C

Claim Paid at Submitted Usual and Customary cost

Pending Review

Pending Review

WAC

Claim paid at WAC pricing

AWP

Claim paid at the contracted AWP rate

PatPay

Non MAC Claim

ZERO

Non MAC Claim

CLIENT MAC

Contact client to review claim

Claim Paid according to effective rate contracted

Claim Paid at the Contracted Rate

PLAN MAC

Claim Paid at the Contracted Rate

NADAC

Claim paid at NADAC pricing

AAC

Claim paid at the contracted AAC rate

AACLA

Claim paid at the contracted AAC rate

MACGSM

Claim Paid at the Contracted Rate

GMAC

Georgia Medicaid MAC Pricing

 

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