Magellan Rx Management Provider Manual

1 Magellan Rx Management Provider Manual Version June 5, 2019. Proprietary & Confidential 2019 Magellan Health, Inc. All rights reserved. Procedure Number: NE-04. Revision History Document Date Name Comments Version 04/24/2014 Pharmacy Network Services Initial creation 05/20/2014 Pharmacy Network Services Information for SFCCN was added 06/06/2014 Pharmacy Network Services Information for MCC FL was added 12/15/2015 Pharmacy Network Medicare Part D section added, contact Operations information updated 03/08/2017 Joy Gimm Annual Review; Revisions 03/30/2018 Joy Gimm Annual Review; Audit language updates, addition of FL and VA Regulatory Addendums 06/05/2019 Joy Gimm and Lori Hoard Annual Review; Updated House Account name to Health Account; Added Definitions Page 2 | Magellan Rx Management Provider Manual Procedure Number: NE-04.

2 Table of Contents Introduction ..7. Magellan Pharmacy Program .. 7. Pharmacy Relations ..8. Enrolling as an Approved Pharmacy .. 8. Pharmacy Network Application and Disclosure Process .. 8. Fraud, Waste, Abuse, and Program Integrity .. 9. Right to Inspection by Government Entities .. 11. Monthly Screening Requirements and Exclusion from Participation in Government Health Care Programs .. 12. Compliance with Legal 13. Incorporation by Reference of Federal and State 13. HIPAA Compliance .. 13. Provider Credentialing .. 17. Member Complaints .. 18. Medication Error 18. Pharmacy Dispute Process .. 18. Pharmacy Suspension Process .. 19. Billing Information .. 21. Claim Formats and Plan Specific Values .. 21. Magellan WebsitePharmacy Portal .. 21. Magellan Services Call Center .. 22. Pharmacy SupportCenter.

3 22. Clinical Support Call Center .. 22. Web Support Call Center .. 23. Program Setup .. 24. Claim Format .. 24. Point-of-Sale NCPDP Version .. 24. Supported POS Transaction Types .. 25. Required Data 26. Paper Claims .. 28. Service 29. Online Certification .. 29. Solving Technical Problems .. 29. Online Claims Processing Edits .. 31. Paid, Denied, and Rejected Responses .. 31. Duplicate Response .. 31. Program Specifications .. 32. Timely Filing Limits .. 32. Magellan Rx Management Provider Manual | Page 3. Mandatory Generic Requirements .. 32. Dispensing Limits/Claim Restrictions .. 32. Days' Supply .. 33. 33. Dollar Limit .. 33. Minimum/Maximum Age Limits .. 33. Refills .. 33. Provider Reimbursement .. 34. Provider Reimbursement Rates .. 34. Plan Co-Pays .. 34. Prior Authorizations.

4 34. Clinical PAs .. 34. Emergency Protocols .. 34. Preferred Drug List (PDL)/PA/Quantity/Duration Lists .. 36. ProDUR Drug Utilization Review .. 36. Drug Utilization Review Edits .. 36. ProDUR Overrides .. 37. Retro DUR .. 40. Special Participant Conditions .. 42. Lock-In .. 42. Compound 42. Fields Required for Submitting Multi-Ingredient Compounds .. 43. Partial Fills .. 43. Coordination of Benefits .. 45. COB General Instructions .. 45. COB 45. Appendix A: Plan Payer Specification .. 49. Appendix B: Point-of-Sale Reject Codes and Messages .. 50. Version Reject Codes for Telecommunication Standard .. 50. Appendix C: State Medicaid Regulatory Requirements .. 61. Florida Regulatory Addendum .. 61. Appendix D: GatorCare .. 64. Pharmacy Application and Agreement and Pharmacy Disclosure Form.

5 64. Website Pharmacy Portal .. 65. Pharmacy Support Center .. 65. Clinical Support Center .. 66. Web Support .. 66. Universal Claim Form .. 66. Request a Contract for Extended Days' Supply Participation .. 66. Pharmacy Contracts for Provider Reimbursement 66. Page 4 | Magellan Rx Management Provider Manual Procedure Number: NE-04. Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, Duration of Edits 67. Payer Specification Document .. 67. Contact Information .. 67. Appendix E: Magellan Health Account .. 69. Pharmacy Application and Agreement and Pharmacy Disclosure Form .. 69. Website Pharmacy Portal .. 70. Pharmacy Support Center .. 70. Clinical Support Center .. 71. Web Support .. 71. Universal Claim Form .. 71. Request a Contract for Extended Days' Supply Participation.

6 71. Pharmacy Contracts for Provider Reimbursement 71. Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration of Edits .. 72. Payer Specification Document .. 72. Contact Information .. 72. Appendix F: Magellan Complete Care .. 74. Pharmacy Application and Agreement and Pharmacy Disclosure Form .. 74. Website Portal .. 75. Pharmacy Support Center .. 75. Clinical Support Center .. 76. Web Support .. 76. Universal Claim Form .. 76. Request a Contract for Extended Days' Supply Participation .. 76. Pharmacy Contracts for Provider Reimbursement 76. Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration of Edits .. 77. Payer Specification Document .. 77. Contact Information .. 77. Appendix G: Community Care Plan (CCP) .. 79. Pharmacy Application and Agreement and Pharmacy Disclosure Form.

7 79. Website Pharmacy Portal .. 80. Pharmacy Support Center .. 80. Clinical Support Center .. 80. Web Support .. 81. Universal Claim Form .. 81. Request a Contract for Extended Days' Supply Participation .. 81. Pharmacy Contracts for Provider Reimbursement 81. Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration of Edits .. 81. Magellan Rx Management Provider Manual | Page 5. Payer Specification Document .. 82. Contact Information .. 82. Appendix H: Magellan Rx Medicare Part D (PDP) Network .. 84. Services .. 84. Claim Processing .. 84. Prescription Origin Code .. 84. Pharmacy/Prescriber Participation .. 85. Electronic Prescribing .. 85. Compliance with Legal Regulations .. 85. Fraud, Waste, and Abuse (FWA) Integrity Program .. 86. Reporting Fraud, Waste, and Abuse.

8 86. Pharmacy Help Desk .. 86. CMS Part D Guidance for Pharmacies .. 86. RxBIN/RxPCN/RxGRP Requirements Medicare Part D .. 86. Eligibility Validation .. 87. Low Income Subsidy (LIS) Change in Status .. 87. Disaster Declaration .. 87. Best Available Evidence (BAE) .. 87. Medicare Part D Claims Adjustment .. 89. General Medicare Part D Submission Requirements for 89. Emergency Overrides .. 89. Marketing .. 89. Tamper Resistant Pads .. 89. Medication Error 90. Formulary Transition Fill Process .. 90. Rejected Claims and Notice to Appeal .. 91. Reject Messaging for Part B versus Part D Drug Coverage Determination .. 91. End Stage Renal Disease (ESRD) Custom Reject Messaging .. 92. Long Term Care Pharmacy Providers .. 92. Claim Types .. 93. LTC Override Requests Short Cycle / Emergency Supply.

9 93. Serving Members in an LTC 93. LTC Billing .. 94. Maximum Allowable Cost (MAC) .. 95. MAC List Disputes (Appeal Process) .. 95. Definitions .. 107. Index .. 109. Page 6 | Magellan Rx Management Provider Manual Procedure Number: NE-04. Introduction Magellan Rx Management , a division of Magellan Health, Inc. ( Magellan ) is the Pharmacy Benefit Manager (PBM) for the Plan. As the PBM, Magellan will administer the point-of-sale (POS) system to process pharmacy claim transactions. The POS will accept pharmacy transactions in the National Council for Prescription Drug Programs (NCPDP). standardized version ; lower versions will not be accepted. After submission, Magellan will respond to the pharmacy Provider with information regarding member eligibility, the Plan allowed amount, applicable Prospective Drug Utilization Review (ProDUR) messages, and applicable rejection messages.

10 ProDUR. messages will be returned in the DUR response fields. Other important related information will appear in the free-form message area. In addition to POS claims, Magellan will accept claims from approved providers via electronic batch on diskettes or through file transfer protocol (FTP). The format for an electronic media is NCPDP Batch version All arrangements with switching companies and software vendors should be handled directly by the Provider with their preferred vendor. Magellan Pharmacy Program This Manual provides claims submission guidelines for the various pharmacy programs administered by Magellan . Important Plan coverage and reimbursement policies are available in this Magellan Rx Management Provider Manual . The Magellan website contains a link to this document. Subsequent revisions to this document are available on each client's Web portal.