Magellan Rx Management Provider Manual

Magellan Rx Management

Provider Manual

Version 4.7

August 6, 2020

Proprietary & Confidential

? 2014¨C2020 Magellan Health, Inc. All rights reserved.

Procedure Number: NE-04

Revision History

Document

Version

Date

Name

Comments

1.0

04/24/2014 Pharmacy Network Services Initial creation

1.1

05/20/2014 Pharmacy Network Services Information for SFCCN was added

1.2

06/06/2014 Pharmacy Network Services Information for MCC FL was added

1.3

12/15/2015 Pharmacy Network

Operations

Medicare Part D section added, contact

information updated

2.0

03/08/2017 Joy Gimm

Annual Review; Revisions

3.0

03/30/2018 Joy Gimm

Annual Review; Audit language updates,

addition of FL and VA Regulatory Addendums

4.0

06/05/2019 Joy Gimm and Lori Hoard

Annual Review; Updated House Account

name to Health Account; Added Definitions

4.1

11/26/2019 Lori Hoard

Moved contact section from 2.1.1.1 to 2.0,

updated GatorCare portal image

4.2

03/02/2020 Communication and

Documentation

Management

Added new state regulatory addenda to

Appendix C

4.3

03/18/2020 Communication and

Documentation

Management

Added five additional state regulatory

addenda to Appendix C

4.4

05/08/2020 Communication and

Documentation

Management

Added 11 additional state regulatory addenda

to Appendix C

4.5

06/03/2020 Lori Hoard

Annual Review

4.6

06/22/2020 Communication and

Documentation

Management

Updated all portal URLs and added eight

state regulatory addenda to Appendix C

4.7

08/06/2020 Communication and

Documentation

Management

Remove the word ¡°Medicaid¡± from Appendix C

title

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Procedure Number: NE-04

Table of Contents

1.0

Introduction ..........................................................................................................................9

1.1

Magellan Pharmacy Program ...................................................................................................... 9

2.0

Pharmacy Relations .............................................................................................................10

2.1

Enrolling as an Approved Pharmacy .......................................................................................... 10

2.1.1 Pharmacy Network Application and Disclosure Process ....................................................... 11

2.1.2 Fraud, Waste, Abuse, and Program Integrity ........................................................................ 11

2.1.3 Right to Inspection by Government Entities ......................................................................... 13

2.1.4 Monthly Screening Requirements and Exclusion from Participation in Government Health

Care Programs ....................................................................................................................... 14

2.1.5 Compliance with Legal Regulations....................................................................................... 15

2.1.6 Incorporation by Reference of Federal and State Law/Regulation....................................... 15

2.1.7 HIPAA Compliance ................................................................................................................. 15

2.2

Provider Credentialing............................................................................................................... 19

2.3

Member Complaints .................................................................................................................. 19

2.4

Medication Error Reporting....................................................................................................... 20

2.5

Pharmacy Dispute Process ........................................................................................................ 20

2.6

Pharmacy Suspension Process .................................................................................................. 21

3.0

Billing Information ...............................................................................................................23

3.1

Claim Formats and Plan ¨C Specific Values ................................................................................. 23

3.2

Magellan Website Pharmacy Portal .......................................................................................... 23

4.0

Magellan Services Call Center ...............................................................................................24

4.1

Pharmacy Support Center ......................................................................................................... 24

4.2

Clinical Support Call Center ....................................................................................................... 24

4.3

Web Support Call Center ........................................................................................................... 25

5.0

Program Setup .....................................................................................................................26

5.1

Claim Format ............................................................................................................................. 26

5.2

Point-of-Sale ¨C NCPDP Version D.0 ........................................................................................... 26

5.2.1 Supported POS Transaction Types ........................................................................................ 27

5.2.2 Required Data Elements........................................................................................................ 28

5.3

Paper Claims .............................................................................................................................. 30

6.0

Service Support....................................................................................................................31

6.1

Online Certification ................................................................................................................... 31

6.2

Solving Technical Problems ....................................................................................................... 31

7.0

Online Claims Processing Edits .............................................................................................33

7.1

Paid, Denied, and Rejected Responses ..................................................................................... 33

7.2

Duplicate Response ................................................................................................................... 33

8.0

Program Specifications .........................................................................................................34

8.1

Timely Filing Limits .................................................................................................................... 34

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8.2

Mandatory Generic Requirements ............................................................................................ 34

8.3

Dispensing Limits/Claim Restrictions ........................................................................................ 35

8.3.1 Days¡¯ Supply .......................................................................................................................... 35

8.3.2 Quantity................................................................................................................................. 35

8.3.3 Dollar Limit ............................................................................................................................ 35

8.3.4 Minimum/Maximum Age Limits ........................................................................................... 35

8.3.5 Refills ..................................................................................................................................... 36

8.4

Provider Reimbursement .......................................................................................................... 36

8.4.1 Provider Reimbursement Rates ............................................................................................ 36

8.5

Plan Co-Pays .............................................................................................................................. 36

8.6

Prior Authorizations .................................................................................................................. 36

8.6.1 Clinical PAs ............................................................................................................................ 36

8.6.2 Emergency Protocols ............................................................................................................. 37

8.6.3 Preferred Drug List (PDL)/PA/Quantity/Duration Lists ......................................................... 38

8.7

ProDUR Drug Utilization Review ............................................................................................... 39

8.7.1 Drug Utilization Review Edits ................................................................................................ 39

8.7.2 ProDUR Overrides ................................................................................................................. 40

8.8

Retro DUR .................................................................................................................................. 42

8.9

Special Participant Conditions ................................................................................................... 44

8.9.1 Lock-In ................................................................................................................................... 44

8.10 Compound Claims...................................................................................................................... 44

8.10.1 Fields Required for Submitting Multi-Ingredient Compounds .............................................. 45

8.11 Partial Fills ................................................................................................................................. 46

9.0

Coordination of Benefits ......................................................................................................47

9.1

COB General Instructions .......................................................................................................... 47

9.1.1 COB Process........................................................................................................................... 47

10.0 Appendix A: Plan D.0 Payer Specification ..............................................................................51

11.0 Appendix B: Point-of-Sale Reject Codes and Messages ..........................................................52

11.1 Version D.0 Reject Codes for Telecommunication Standard .................................................... 52

12.0 Appendix C: State Regulatory Requirements .........................................................................63

12.1 Alabama ..................................................................................................................................... 63

12.2 Alaska......................................................................................................................................... 65

12.3 Arizona ....................................................................................................................................... 68

12.4 Arkansas .................................................................................................................................... 71

12.5 California ................................................................................................................................... 73

12.6 Colorado .................................................................................................................................... 82

12.7 Connecticut................................................................................................................................ 87

12.8 Delaware.................................................................................................................................... 90

12.9 District of Columbia ................................................................................................................... 92

12.10 Florida ........................................................................................................................................ 94

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Magellan Rx Management Provider Manual

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