Learn which services need prior authorizations, which services are not covered, and which are not medically necessary.
As of May 1, 2018, EOCCO will apply new Morphine Equivalent Dose (MED) edits
These edits will stop pharmacy claims at point of sale (POS) for additional review for all diagnoses. There are two levels of review..
- Soft POS edit (90-200 MED). The soft POS edit will stop claims between 90 MED and 200 MED for the dispensing pharmacist to review. If the pharmacist approves, the pharmacy can override the claim at POS and dispense to the member.
- Hard POS edit (200+ MED). The hard POS edit will stop claims for members with 200+ MED. It will require a clinical prior authorization before dispensing.
The following tools are EOCCO’s referral and authorization guidelines and instructions. They can help you understand prior authorization request requirements and other medical services that do not require authorization.