D.0 Pharmacy Claims Processing Manual - Magellan Rx Management

D.0 Pharmacy Claims Processing Manual

For the Michigan Department of Health and Human Services (MDHHS) Medicaid Children's Special Health Care Services (CSHCS) Healthy Michigan Plan (HMP) Maternity Outpatient Medical Services (MOMS)

Version 1.54

January 25, 2024

Proprietary & Confidential ? 2006?2024 Magellan Rx Management. All rights reserved. Magellan Medicaid Administration is a division of Magellan Rx Management, LLC.

Revision History

Version Date

Name

1.0 06/26/2006 Plan Administration

1.1 08/08/2006 Plan Administration

1.2 08/08/2006 Documentation Mgmt.

1.3 04/18/2007 Plan Administration; Documentation Mgmt.

1.4 05/11/2007 Plan Administration; Documentation Mgmt.

1.5 06/18/2007 Plan Administration; Documentation Mgmt.

1.6 07/09/2007 Plan Administration; Documentation Mgmt.

1.7 08/01/2007 Plan Administration; Documentation Mgmt.

1.8 12/03/2007 Plan Administration; Documentation Mgmt.

1.9 12/21/2007 Plan Administration; Documentation Mgmt.

1.10 02/06/2008 Plan Administration; Documentation Mgmt.

1.11 03/14/2008 Plan Administration; Documentation Mgmt.

1.12 03/28/2008 Plan Administration; Documentation Mgmt.

1.13 03/31/2008 Plan Administration; Documentation Mgmt.

1.14 04/23/2008 Plan Administration; Documentation Mgmt.

1.15 05/13/2008 Plan Administration; Documentation Mgmt.

1.16 05/19/2008 Plan Administration; Documentation Mgmt.

1.17 07/08/2008 Plan Administration; Documentation Mgmt.

1.18 10/27/2008 Plan Administration; Documentation Mgmt.

1.19 11/05/2008 Plan Administration; Documentation Mgmt.

Comments First updated version since 5.1 version effective August 14, 2003 Maintenance Drug List was updated, and the Payer Specifications was changed to reflect that MIC will be implemented at an undetermined future date Reviewed, formatted, proofread Updated with new Payer Specification content that was updated with NPI information Updated sections 4.4 and 7.8

Updated page 16, 75 (M/I Prescriber ID), and 78 (NonMatched Prescriber ID) Updated footers with version number and date

Added section 7.4.1; adjusted numbering to accommodate new section Updated section 7.5, Prior Auth (table 8); added "Narcotics ? Early Refills" Updated section 7.8.1

Updated section 8.1.3; updated formatting

Updated footers with version number and date; updated sections 4.4 and 7.8; deleted section 7.8.1 Updated Page 44 ? Field Requirement Table updated for 419DJ. Section 7.10 updated to reflect April 1, 2008 changes for Unit Dose Incentive Fees Updated section 7.1 ? Timely Filing Limits

Updated Appendix A

Updated Field #466-EZ, 411-DB, and Appendix B

Updated Section 2.1

Updated Appendix A, Appendix B, and added Section 7.12

Updated Section 2.1

Updated Section 2.2 and last note under Section 7.8

D.0 Pharmacy Claims Processing Manual for the Michigan Department of Health and Human Services

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Version Date

Name

Comments

1.20 11/06/2008 Documentation Mgmt. Updated footers

1.21 01/06/2009 Plan Administration; Updated NCPDP website address and standardized Documentation Mgmt.

1.22 04/08/2009 Plan Administration; Updated Appendix G Documentation Mgmt.

1.23 11/11/2009 Account/Contract Mgmt/ Updated Sections 1.1, 1.2, 2.3, 3.3, 4.2.2, 7.1, 7.8, 8.11, Documentation Mgmt. Appendix A, Appendix D, and Appendix F Added Section 7.13

1.24 02/16/2010 Documentation Mgmt. Updated Magellan Medicaid Administration address

1.25 06/02/2010 Sherrill Bryant;

Standardized

Documentation Mgmt.

1.26 12/09/2010 Plan Administration

Updated sections 2.3, 4.4, 7.1, 7.4, 7.4.1, 7.6.3, 7.7.2, 7.13.2, 8.1.3, 8.2.2, and Appendix A

1.27 02/09/2011 Linwood Schools;

Updated 7.4.1

Documentation Mgmt.

1.28 08/22/2011 Sherrill Bryant;

Updated for D.0

Documentation Mgmt.

1.29 10/20/2011 Sherrill Bryant;

Updated Appendix A

Documentation Mgmt.

1.30 11/16/2011 Sherrill Bryant;

Updated Appendix A

Documentation Mgmt.

1.31 09/21/2012 Bradley Vaught;

Updated Magellan Addresses, Appendix D, and 7.13.2

Documentation Mgmt.

1.32 12/04/2012 Bradley Vaught;

Updated Section 8.2.3

Documentation Mgmt.

1.33 03/25/2013 Bradley Vaught

Updated Directory. Updated section 8.2.3

1.34 06/03/2013 Bradley Vaught

Updated any reference to maintenance days' supply from 100 to 102

1.35 03/24/2015 Bradley Vaught

Added payer specs to Appendix A

1.36 06/10/2015 Paul Lunsford;

Updated Michigan Department of Health and Human

Documentation Mgmt. Services name (from Michigan Department of Community

Health); rebranded doc with new MRx logo and template

1.37 02/01/2016 Paul Lunsford;

Updated Payer Spec Appendix A

Documentation Mgmt.

1.38 12/08/2017 Andrea Mullins

Updated Sections 7.13.1, 7.13.2, Appendix F (Table 12NCPDP Reject Code 32)

1.39 05/19/2018 Jeanne Bailey;

Updated Cover Sheet

Documentation Mgmt. Updated Sections 1,1 MDHHS Pharmacy Programs

Updated Section 1.2 Pharmacy Benefit Manager ?Magellan Medicaid Administration

Updated Section 2.1 Enrolling as an MDHHS-Approved Pharmacy

Removed Section 2.2 Undelivered Mail

Renumbered Sections

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D.0 Pharmacy Claims Processing Manual for the Michigan Department of Health and Human Services

Version Date

Name

1.40 09/23/2019 Jeanne Bailey

1.41 10/29/2019 Jeanne Bailey; Documentation Mgmt.

1.42 01/03/2020 Jeanne Bailey; Documentation Mgmt.

Comments Updated Section 4.2.2 Required Data Elements Updated Section 4.4 Paper Claim ? Universal Claim Form (UCF) Updated Section 7.5 Prior Authorization Table 8 Updated Section 7.6.2 Lock-In Beneficiaries Created Section 7.6.4 Emergency Services Only (ESO) Eligibility Updated Section 7.7 Managed Care Plans and Pharmacy Carve-Out Lists Updated Section 7.7.1 Pharmacy Carve-Outs Updated Section 7.7.2 Michigan Medicaid Health Plan CarveOuts Removed Section 7.7.3 Adult Benefits Waiver-County Health Carve Out Updated Section 7.8 Compound Claims Removed Section 7.9 Home Infusion Therapy Claims Updated Section 7.3 Vaccine Submissions Updated Section 7.13.1 H1N1 Vaccine Updated Section 7.13.2 Seasonal Flu Vaccine Created Section 7.13.3 Other Vaccines Created Section 7.14 Professional Dispensing Fee Updated Section 8.1.1 Carrier ID List Updated Section 8.2.3 Medicare Part D Updated Appendix A ? Payer Specifications for NCPDP D.0 Updated Appendix E ? ProDUR Updated Appendix F ? POS Reject Codes and Messages Updated Appendix G ? Directory

Updated Web Portal URL throughout manual Updated 7.1 Timely Filing Limits Updated formatting Created Section 9.0 Prescriber Enrollment Requirement Removed Section 7.12.1 H1N1 Renumbered Section 7.12.2 Seasonal Flu Vaccine Renumbered Section 7.12.3 Other Vaccines

Updated Appendix G ? Directory Mailing Addresses for Claims Submission Updated Section 2.2 Magellan Medicaid Administration Website for MDHHS Updated Section 7.4 Maximum Allowable Cost (MAC) Rates Updated 7.4.1 MAC Pricing or Appeal/Raise Issues Updated 5.2 Electronic Funds Transfer (EFT) Updated 5.3 Electronic Remittance Advice Rebranded, formatted, and reviewed document

Updated Section 2.2 Magellan Medicaid Administration Website for MDHHS

D.0 Pharmacy Claims Processing Manual for the Michigan Department of Health and Human Services

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Version Date

Name

Comments

1.43 09/11/2020 Jeanne Bailey;

Updated Section 3.2 Clinical Support Center

Documentation Mgmt. Created Sections 7.11.4 Initial Incremental Fill for CII Drugs

and 7.11.5 Subsequent Incremental Fill for CII Drugs

Updated Section 8.1.1 Identifying Other Insurance Coverage

Updated Section 8,2.1 Identifying Individuals Enrolled in Medicare

Created Section 10.0 Brand Versus Generic Requirements

Created Section 11.0 COVID-19

Updated Appendix A Payer Specifications for NCPDP D.0

Updated Appendix E ProDUR-DUR Professional Service

Updated Appendix F Point-of-Sale Reject Codes and Messages

1.44 01/05/2021 Jeanne Bailey;

Created Section 11.3 COVID-19 Vaccine Claim Process

Documentation Mgmt. Created Section 11.3.1 COVID-19 Reimbursement Logic

Updated Appendix A Payer Specifications for NCPDP D.0

1.45 03/02/2021 Jeanne Bailey;

Updated Section 7.9 Home Infusion Therapy Claims

Documentation Mgmt. Renumbered Section 7.10 through 7.14

Updated Section 11.3 COVID-19 Vaccine Claim Process

Updated Appendix A Payer Specifications for NCPDP D.0

1.46 04/06/2021 Jeanne Bailey;

Updated Section 11.3.1 COVID-19 Vaccine Reimbursement

Documentation Mgmt. Logic

1.47 04/21/2021 Jeanne Bailey;

Updated Section 8.2.1 Identifying Individuals Enrolled in

Documentation Mgmt. Medicare

1.48 08/30/2021 Jeanne Bailey;

Created Section 11.4 COVID-19 Vaccine Pharmacy Billing for

Documentations Mgmt. Additional Doses and Place of Residence Administration

Updated Appendix Payer Specifications for NCPDP D.O

Field 307-C7 Place of Service, Field 419-DJ Prescription

Origin Code, and Field 420-DK Submission Clarification

Code,

1.49 11/17/2021 Jeanne Bailey;

Updated Section 7.1 Timely Filing Limits

Documentation Mgmt.

1.50 12/13/2021 Jeanne Bailey;

Created Section 11.5 COVID-19 Home Tests

Documentation Mgmt.

1.51 1/04/2023 Donna Johnson;

Created Section 7.15 Clinical Trial Attestation Policy

Documentation Mgmt.

1.52 11/30/2023 Donna Johnson;

Removed Section 11.2 Medicaid Pharmacy Flexibilities;

Documentation Mgmt Revised and renumbered Section 11.3.1 COVID-19 Vaccine

Reimbursement Logic; revised and renumbered Section 11.4

COVID-19 Vaccine Pharmacy Billing for Additional Doses and

Place of Residence Administration

1.53 12/27/2023 Donna Johnson;

Created Section 8.1.5 Discount Card/Discount Benefit

Documentation Mgmt Response from Primary Insurance - Medicaid COB

Requirements

Revised Section 11.2.1 COVID-19 Vaccine Reimbursement

Logic

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D.0 Pharmacy Claims Processing Manual for the Michigan Department of Health and Human Services

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