Qualchoice.magellanrx.com
Magellan Rx Management
Provider Manual
Proprietary & Confidential ? 2014-2024 All rights reserved. Magellan Rx Management LLC, a Prime Therapeutics company
Table of Contents
1.0 Introduction ..........................................................................................................................6 1.1 MRx Pharmacy Program .............................................................................................................. 6
2.0 Pharmacy Relations ...............................................................................................................7 2.1 Enrolling as an Approved Pharmacy............................................................................................ 7 2.2 Credentialing and Quality Management ................................................................................... 22 2.3 Member Complaints.................................................................................................................. 25 2.4 Medication Error Reporting....................................................................................................... 25 2.5 Pharmacy Dispute Process ........................................................................................................ 25 2.6 Pharmacy Suspension Process .................................................................................................. 26
3.0 Billing Information ...............................................................................................................28 3.1 Claim Formats and Plan ? Specific Values ................................................................................. 28 3.2 Magellan Rx Management (MRx) Website Pharmacy Portal .................................................... 28
4.0 Call Center Services..............................................................................................................29 4.1 Pharmacy Support Center ......................................................................................................... 29 4.2 Clinical Support Call Center ....................................................................................................... 29 4.3 Web Support Call Center ........................................................................................................... 29
5.0 Program Setup.....................................................................................................................30 5.1 Claim Format ............................................................................................................................. 30 5.2 Point-of-Sale ? NCPDP Version D.0 ........................................................................................... 30 5.3 Paper Claims .............................................................................................................................. 33
6.0 Service Support....................................................................................................................35 6.1 Online Certification ................................................................................................................... 35 6.2 Solving Technical Problems ....................................................................................................... 35
7.0 Online Claims Processing Edits .............................................................................................36 7.1 Paid, Denied, and Rejected Responses ..................................................................................... 36 7.2 Duplicate Response ................................................................................................................... 36
8.0 Program Specifications.........................................................................................................37 8.1 Timely Filing Limits .................................................................................................................... 37 8.2 Mandatory Generic Requirements............................................................................................ 37 8.3 Dispensing Limits/Claim Restrictions ........................................................................................ 37 8.4 Provider Reimbursement .......................................................................................................... 38 8.5 Plan Co-Pays .............................................................................................................................. 39 8.6 Prior Authorizations .................................................................................................................. 39 8.7 ProDUR Drug Utilization Review ............................................................................................... 41 8.8 Retro DUR .................................................................................................................................. 44 8.9 Special Participant Conditions ................................................................................................... 46 8.10 Compound Claims...................................................................................................................... 46
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8.11 Partial Fills ................................................................................................................................. 47 9.0 Coordination of Benefits ......................................................................................................49
9.1 COB General Instructions .......................................................................................................... 49 10.0 Appendix A: Plan D.0 Payer Specification..............................................................................53 11.0 Appendix B: Point-of-Sale Reject Codes and Messages ..........................................................54
11.1 Version D.0 Reject Codes for Telecommunication Standard .................................................... 54 12.0 Appendix C: State Regulatory Requirements.........................................................................65
12.1 Medicare Part D......................................................................................................................... 65 12.2 Alabama..................................................................................................................................... 81 12.3 Alaska......................................................................................................................................... 83 12.4 Arizona....................................................................................................................................... 85 12.5 Arkansas .................................................................................................................................... 87 12.6 California ................................................................................................................................... 88 12.7 Colorado .................................................................................................................................... 97 12.8 Connecticut.............................................................................................................................. 102 12.9 Delaware.................................................................................................................................. 105 12.10 District of Columbia ................................................................................................................. 106 12.11 Florida...................................................................................................................................... 107 12.12 Georgia .................................................................................................................................... 112 12.13 Hawaii ...................................................................................................................................... 114 12.14 Idaho........................................................................................................................................ 115 12.15 Illinois....................................................................................................................................... 117 12.16 Indiana ..................................................................................................................................... 120 12.17 Iowa ......................................................................................................................................... 124 12.18 Kansas ...................................................................................................................................... 126 12.19 Kentucky .................................................................................................................................. 127 12.20 Louisiana.................................................................................................................................. 130 12.21 Maine....................................................................................................................................... 131 12.22 Maryland ................................................................................................................................. 133 12.23 Massachusetts ......................................................................................................................... 136 12.24 Michigan .................................................................................................................................. 138 12.25 Minnesota................................................................................................................................ 142 12.26 Mississippi ............................................................................................................................... 145 12.27 Missouri ................................................................................................................................... 147 12.28 Montana .................................................................................................................................. 152 12.29 Nebraska.................................................................................................................................. 154 12.30 Nevada..................................................................................................................................... 161 12.31 New Hampshire ....................................................................................................................... 163 12.32 New Jersey............................................................................................................................... 165 12.33 New Mexico............................................................................................................................. 172
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12.34 New York ................................................................................................................................. 175 12.35 North Carolina ......................................................................................................................... 188 12.36 North Dakota ........................................................................................................................... 191 12.37 Ohio ......................................................................................................................................... 192 12.38 Oklahoma ................................................................................................................................ 196 12.39 Oregon..................................................................................................................................... 197 12.40 Pennsylvania............................................................................................................................ 198 12.41 Rhode Island ............................................................................................................................ 202 12.42 South Carolina ......................................................................................................................... 204 12.43 South Dakota ........................................................................................................................... 205 12.44 Tennessee................................................................................................................................ 207 12.45 Texas........................................................................................................................................ 208 12.46 Utah ......................................................................................................................................... 213 12.47 Vermont................................................................................................................................... 214 12.48 Virginia..................................................................................................................................... 217 12.49 Washington ............................................................................................................................. 223 12.50 West Virginia ........................................................................................................................... 227 12.51 Wisconsin ................................................................................................................................ 232 12.52 Wyoming ................................................................................................................................. 238 13.0 Appendix D: Magellan Rx Management (MRx) Account.......................................................239 13.1 Pharmacy Application and Agreement and Pharmacy Disclosure Form................................. 239 13.2 Website Pharmacy Portal ........................................................................................................ 240 13.3 Pharmacy Support Center ....................................................................................................... 240 13.4 Clinical Support Center............................................................................................................ 240 13.5 Web Support ........................................................................................................................... 241 13.6 Universal Claim Form .............................................................................................................. 241 13.7 Request a Contract for Extended Days' Supply Participation ................................................. 241 13.8 Pharmacy Contracts for Provider Reimbursement Rates........................................................ 241 13.9 Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration of
Edits ......................................................................................................................................... 241 13.10 Payer Specification Document ................................................................................................ 241 13.11 Contact Information ................................................................................................................ 242 14.0 Appendix E: Community Care Plan (CCP).............................................................................243 14.1 Pharmacy Application and Agreement and Pharmacy Disclosure Form................................. 243 14.2 Website Pharmacy Portal ........................................................................................................ 244 14.3 Pharmacy Support Center ....................................................................................................... 244 14.4 Clinical Support Center............................................................................................................ 244 14.5 Web Support ........................................................................................................................... 244 14.6 Universal Claim Form .............................................................................................................. 244 14.7 Request a Contract for Extended Days' Supply Participation ................................................. 244
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14.8 Pharmacy Contracts for Provider Reimbursement Rates........................................................ 245 14.9 Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration of
Edits ......................................................................................................................................... 245 14.10 Payer Specification Document ................................................................................................ 245 14.11 Contact Information ................................................................................................................ 245 15.0 Appendix F: Medicare Part D Network................................................................................247 15.1 Services.................................................................................................................................... 247 15.2 Claim Processing...................................................................................................................... 247 15.3 Compliance with Legal Regulations......................................................................................... 248 15.4 Pharmacy Help Desk................................................................................................................ 249 15.5 Eligibility Validation ................................................................................................................. 249 15.6 Low Income Subsidy (LIS) Change in Status ............................................................................ 249 15.7 Disaster Declaration ................................................................................................................ 250 15.8 Best Available Evidence (BAE) ................................................................................................. 250 15.9 Medicare Part D Claims Adjustment ....................................................................................... 251 15.10 General Medicare Part D Submission Requirements for COB................................................. 251 15.11 Emergency Overrides .............................................................................................................. 252 15.12 Marketing ................................................................................................................................ 252 15.13 Tamper Resistant Pads ............................................................................................................ 252 15.14 Medication Error Reporting..................................................................................................... 252 15.15 Formulary Transition Fill Process ............................................................................................ 252 15.16 Reject Messaging for Part B versus Part D Drug Coverage Determination............................. 254 15.17 End Stage Renal Disease (ESRD) Custom Reject Messaging.................................................... 254 15.18 Long Term Care Pharmacy Providers ...................................................................................... 255 15.19 Maximum Allowable Cost (MAC) ............................................................................................ 257 16.0 Appendix G: Discrepancy Code List .....................................................................................259 17.0 Definitions.........................................................................................................................267
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