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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Magellan Rx Management Provider Manual
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
Magellan Rx Management Provider Manual
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Page 3
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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