What is the process for patients going into a nursing home who hit the Refill-Too-Soon edit?
As of September 1, 2002, 80% of a prescription must be used before a recipient receives a refill, otherwise, the claim will be denied. (Prior to September 1, 75% of the prescription had to be used.) If you submit the claim before 80% of the prescription is used, the claim will be denied. In this instance, you may use the prior authorization process if the patient meets one of the following criteria: – Dosage Change – Lost Prescription 1 Refill To Soon override allowed per year The ACS Clinical Call Center will not override the Refill Too Soon edit unless one of these criteria has been met.
