Attention Pharmacy Providers: Updated Technical Instructions for Processing Backlogged Claims​

May 06, 2024

Pharmacy claims resumed processing on March 27, 2024. MaineCare continues to work with Optum to review outstanding rejected claims with dates of service during the system outage. The guidance below applies to claims with dates of service from February 21, 2024, through March 26, 2024. We have updated the technical instructions to reflect these changes. 

Some Reject-76 claims are now eligible for re-adjudication. This includes Max Dose Exceeded, Max Days Supply Exceeded, Claims Days Supply Exceeds Drug Days Supply, Exceeds Allowable Days Supply, Accumulated Qty Exceeds Allowed Amount. These Reject-76 claims do not require an override for processing and pharmacies may resubmit for payment without emailing or contacting the Optum Change Healthcare Helpdesk. 

Some Reject-76 claims remain ineligible for coverage. Reject-76 claims, including No Coverage for Part D Deductible or Gap, No Gap Coverage Available, Prescription Expired, Age Criteria Not Met, indicate that a claim is not eligible for coverage.    

Please contact Optum’s Change Healthcare Pharmacy Provider Help Desk with any questions or for claims assistance at 1-888-420-9711.   

Pharmacies may also email claims assistance requests to MaineHD@optum.com    

MaineCare Pharmacy Service Restoration Office Hours – Friday May 10, 2024 

For additional support, MaineCare is inviting you to join the next Office Hours call with the MaineCare Pharmacy team on Friday, May 10, 2024, from 1 p.m. – 1:45 p.m. related to the current phase of service restoration. We will use this time as an opportunity for sharing questions and concerns and providing technical support from the State. Register in advance for this meeting: https://mainestate.zoom.us/meeting/register/tZAsdemsrDwrEtZSsnll3bd9PQyaK3xC5mYC 

Thank you for your continued support and efforts to serve MaineCare members.