Welcome.
This walkthrough of the Optum Rx MAC
Appeals Submission Template will guide
you step-by-step through the form
to ensure it's properly processed.
At the top of the spreadsheet, rows 9
and 10 show the field names and the
requirements for each column, including whether
a field is required or optional, and any
specific formatting you need to follow.
You'll begin entering your
appeal information on row 13,
and you can enter as many appeals
as needed beneath that row.
In column A, enter the required six-digit
processor BIN associated with the claim.
Column B is for the PCN, which is optional.
In column C, you can enter the
9-character Carrier ID, which is also optional.
In column D, fill in the required
7-digit NCPDP number.
In column E, enter the required prescription
number, which should be 12 digits.
Column F is for the required fill
date, listed in month-month, day
-day, year-year -year-year format.
Column G is for the 11-
digit NDC, also required.
Column H is optional and indicates
whether the claim was a compound.
Select Y or N from the drop-down.
column I is the reason for review,
which is required. Select an
option from the drop-down list.
Column J is the notes field, which
is only required for Tennessee
and optional for other states.
The next several columns involve
acquisition cost, pricing and reimbursement
details. Requirements differ by
state and can be checked in row 10.
Column K is the field for Provider Per Unit
Drug Acquisition Cost No. 1. See the on-
screen list for applicable state requirements.
Column L is the Provider Per
Unit Drug Acquisition Cost No. 2.
This field can be used if you
have a secondary cost source
and is optional for all states.
Column M is for the net purchase price
of the drug. This is required for
New Mexico only, optional elsewhere.
Column N is for total reimbursement,
which is required for New Mexico and
Kansas, and optional for all other states.
Column O is for the drug name, required
for New Mexico only, optional elsewhere.
Column P, for drug strength, is
also only required for New Mexico.
Column Q is for the attestation for Louisiana
only, reading: Attests to Interest or Shared
Pharmaceutical Wholesale Group Purchasing
Organization or Vendor Relationships. For
all other states, you can leave this blank.
Column R, Internal Use Only. Leave this
column blank. It is completed only
by internal Optum Rx processing teams.
Once all required fields are entered, review
each row to ensure formatting and required
fields match the guidance in row 10.
Save the file. Submit it through the Optum
online portal as part of your MAC appeal
workflow. For any question about state-specific
requirements or clarifications, refer
to the guidelines on the MAC Appeals page.