Magellan Rx Management Provider Manual

Magellan Rx Management Provider Manual

Version 4.7 August 6, 2020

Proprietary & Confidential ? 2014?2020 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 ? 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 ? 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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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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