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Magellan Rx ManagementProvider ManualProprietary & Confidential 2014 2022 Magellan Health, Inc. All rights reserved.Magellan Medicaid Administration, part of the Magellan Rx Management division of Magellan Health, Inc.
Table of 48.58.68.78.88.98.10Page 2Introduction .7Magellan Pharmacy Program . 7Pharmacy Relations .8Enrolling as an Approved Pharmacy . 8Credentialing and Quality Management . 24Member Complaints . 26Medication Error Reporting. 26Pharmacy Dispute Process . 27Pharmacy Suspension Process . 28Billing Information .30Claim Formats and Plan – Specific Values . 30Magellan Website Pharmacy Portal . 30Magellan Services Call Center .31Pharmacy Support Center . 31Clinical Support Call Center . 31Web Support Call Center . 31Program Setup .33Claim Format . 33Point-of-Sale – NCPDP Version D.0 . 33Paper Claims . 36Service Support.38Online Certification . 38Solving Technical Problems . 38Online Claims Processing Edits .40Paid, Denied, and Rejected Responses . 40Duplicate Response . 40Program Specifications .41Timely Filing Limits . 41Mandatory Generic Requirements . 41Dispensing Limits/Claim Restrictions . 41Provider Reimbursement . 43Plan Co-Pays . 43Prior Authorizations . 43ProDUR Drug Utilization Review . 45Retro DUR . 48Special Participant Conditions . 50Compound Claims. 50 Magellan Rx Management Provider Manual
8.11 Partial Fills . 529.0Coordination of Benefits .539.1COB General Instructions . 5310.0 Appendix A: Plan D.0 Payer Specification .5711.0 Appendix B: Point-of-Sale Reject Codes and Messages .5811.1 Version D.0 Reject Codes for Telecommunication Standard . 5812.0 Appendix C: State Regulatory Requirements .6912.1 Medicare Part D. 6912.2 Alabama . 8612.3 Alaska. 8712.4 Arizona . 8912.5 Arkansas . 9112.6 California . 9312.7 Colorado . 10112.8 Connecticut. 10612.9 Delaware. 10912.10 District of Columbia . 11112.11 Florida . 11212.12 Georgia . 11412.13 Hawaii . 11612.14 Idaho . 11712.15 Illinois. 11912.16 Indiana . 12212.17 Iowa . 12412.18 Kentucky . 12612.19 Louisiana . 12812.20 Maine. 13012.21 Maryland . 13112.22 Massachusetts . 13412.23 Michigan . 13612.24 Minnesota. 13712.25 Mississippi . 14012.26 Missouri . 14212.27 Montana . 14712.28 Nebraska . 14912.29 Nevada . 15212.30 New Hampshire . 15412.31 New Jersey. 15612.32 New Mexico . 16312.33 New York . 165Magellan Rx Management Provider Manual Page 3
12.34 North Carolina . 17812.35 North Dakota . 18212.36 Ohio . 18312.37 Oklahoma . 18712.38 Oregon . 18812.39 Pennsylvania . 18912.40 Rhode Island . 19312.41 South Carolina . 19512.42 South Dakota . 19612.43 Tennessee . 19712.44 Texas . 19912.45 Utah . 20312.46 Vermont. 20512.47 Virginia . 20812.48 Washington . 21412.49 West Virginia . 21812.50 Wisconsin . 22312.51 Wyoming . 22813.0 Appendix D: GatorCare . 23013.1 Pharmacy Application and Agreement and Pharmacy Disclosure Form . 23013.2 Website Pharmacy Portal . 23113.3 Pharmacy Support Center . 23113.4 Clinical Support Center . 23113.5 Web Support . 23113.6 Universal Claim Form . 23213.7 Request a Contract for Extended Days’ Supply Participation . 23213.8 Pharmacy Contracts for Provider Reimbursement Rates. 23213.9 Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration ofEdits . 23213.10 Payer Specification Document . 23213.11 Contact Information . 23314.0 Appendix E: Magellan Health Account . 23514.1 Pharmacy Application and Agreement and Pharmacy Disclosure Form . 23514.2 Website Pharmacy Portal . 23614.3 Pharmacy Support Center . 23614.4 Clinical Support Center . 23614.5 Web Support . 23714.6 Universal Claim Form . 23714.7 Request a Contract for Extended Days’ Supply Participation . 23714.8 Pharmacy Contracts for Provider Reimbursement Rates. 237Page 4 Magellan Rx Management Provider Manual
14.9Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration ofEdits . 23714.10 Payer Specification Document . 23714.11 Contact Information . 23815.0 Appendix F: Magellan Complete Care . 24015.1 Pharmacy Application and Agreement and Pharmacy Disclosure Form . 24015.2 Website Pharmacy Portal . 24115.3 Pharmacy Support Center . 24115.4 Clinical Support Center . 24115.5 Web Support . 24115.6 Universal Claim Form . 24115.7 Request a Contract for Extended Days’ Supply Participation . 24115.8 Pharmacy Contracts for Provider Reimbursement Rates. 24215.9 Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration ofEdits . 24215.10 Payer Specification Document . 24215.11 Contact Information . 24216.0 Appendix G: Community Care Plan (CCP) . 24416.1 Pharmacy Application and Agreement and Pharmacy Disclosure Form . 24416.2 Website Pharmacy Portal . 24516.3 Pharmacy Support Center . 24516.4 Clinical Support Center . 24516.5 Web Support . 24516.6 Universal Claim Form . 24516.7 Request a Contract for Extended Days’ Supply Participation . 24516.8 Pharmacy Contracts for Provider Reimbursement Rates. 24616.9 Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration ofEdits . 24616.10 Payer Specification Document . 24616.11 Contact Information . 24617.0 Appendix H: Magellan Rx Medicare Part D Network. 24817.1 Services . 24817.2 Claim Processing . 24817.3 Compliance with Legal Regulations . 24917.4 Pharmacy Help Desk . 25017.5 Eligibility Validation . 25017.6 Low Income Subsidy (LIS) Change in Status . 25017.7 Disaster Declaration . 25117.8 Best Available Evidence (BAE) . 25117.9 Medicare Part D Claims Adjustment . 252Magellan Rx Management Provider Manual Page 5
17.10 General Medicare Part D Submission Requirements for COB. 25217.11 Emergency Overrides . 25317.12 Marketing . 25317.13 Tamper Resistant Pads . 25317.14 Medication Error Reporting. 25317.15 Formulary Transition Fill Process . 25317.16 Reject Messaging for Part B versus Part D Drug Coverage Determination . 25517.17 End Stage Renal Disease (ESRD) Custom Reject Messaging . 25517.18 Long Term Care Pharmacy Providers . 25617.19 Maximum Allowable Cost (MAC) . 25818.0 Appendix I: MRx Discrepancy Code List. 26019.0 Definitions . 268Page 6 Magellan Rx Management Provider Manual
1.0IntroductionMagellan Rx Management, a division of Magellan Health, Inc. (“Magellan”) is the PharmacyBenefit 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 pharmacytransactions in the National Council for Prescription Drug Programs (NCPDP) standardizedversion D.0; lower versions will not be accepted.After submission, Magellan will respond to the pharmacy provider with information regardingmember eligibility, the Plan allowed amount, applicable Prospective Drug Utilization Review(ProDUR) messages, and applicable rejection messages. ProDUR messages will be returned inthe DUR response fields. Other important related information will appear in the free-formmessage area.In addition to POS claims, Magellan will accept claims from approved providers via electronicbatch on diskettes or through file transfer protocol (FTP). The format for an electronic media isNCPDP Batch version 1.2.All arrangements with switching companies and software vendors should be handled directlyby the provider with their preferred vendor.1.1Magellan Pharmacy ProgramThis manual provides claims submission guidelines for the various pharmacy programsadministered by Magellan.Important Plan coverage and reimbursement policies are available in this Magellan RxManagement Provider Manual. The Magellan website contains a link to this document.Subsequent revisions to this document are available on each client’s Web portal. Please referto Section 13.0 Appendix D through Section 17.0 – Appendix H of this document to accessclient-specific links.Magellan Rx Management Provider Manual Page 7
2.0Pharmacy RelationsThe Magellan Rx Management Provider Manual addresses the following for participatingpharmacies: Orientation of new participating pharmacies Updates of network activities Changes in state/federal regulatory contracting provisions Provide information to pharmacies on how to obtain information regarding benefits,eligibility, formulary, dispute, and appeals information. How to obtain a current copy of this manual and other documents that describe therelationship between Magellan and participating pharmacies.Should you have any questions, concerns, or suggestions on how to better serve your patients,please contact the Pharmacy Network team at the following:Pharmacy Networks Department11013 West Broad StreetSuite 500Glen Allen, VA 23060-5939 Department Fax Number: 1-804-548-0963 Department Email: RxNetworksDept@magellanhealth.com Joy Gimm, Senior Director, Pharmacy Network Operations1-602-615-3241jgimm@magellanhealth.com Lori Hoard, Director Network Development1-480-624-9443lhoard@magellanhealth.com Gerald Duncan, Manager, Pharmacy Networks Government Programs1-804-548-0112gduncan@magellanhealth.com Mark Douglas, Manager of MAC .1Enrolling as an Approved PharmacyThe Magellan Provider Network consists of contracted pharmacies. To enroll as a Magellanpharmacy provider, please follow the steps in Section 2.1.1 – Pharmacy Network Applicationand Disclosure Process.Page 8 Magellan Rx Management Provider Manual
2.1.1Pharmacy Network Application and Disclosure ProcessAll pharmacies interested in participating in the Magellan Pharmacy Network must submit thefollowing: Provider Application and Agreement Pharmacy Disclosure FormPlease refer to Section 13.0 Appendix D through Section 17.0 Appendix H for client-specificinformation.2.1.1.11.Instructions for Completing the Pharmacy Disclosure FormFill out all sections on the Disclosure of Ownership and Control Interest Statement uponrequest by Magellan.Note: Each pharmacy participating in the Group Purchasing Organization (GPO) or thePharmacy Services Administration Organization (PSAO) MUST be monitored andreported to PBM by the PSAO entity on an annual basis and monitored against the Listof Excluded Individuals and Entities (LEIE) maintained by the Office of Inspector General(OIG) and the System for Award Management (SAM) exclusion lists on a monthly basis.Any participating pharmacies or owners and their pharmacy confirmed as excludedmust be removed from the PSAO Network immediately and reported to PBM uponremoval. Return the completed form to PBM and fax to 1-888-656-4139.Please refer to Section 13.0 Appendix D through Section 17.0 Appendix H for client-specificinformation.2.1.2Fraud, Waste, Abuse, and Program IntegrityMagellan takes provider fraud, waste, and abuse seriously. We engage in considerable effortsand dedicate substantial resources to prevent these activities and to identify those committingviolations. Magellan has made a commitment to actively pursue all suspected cases of fraud,waste, and abuse and will work with law enforcement for full prosecution under the law.Our expectation is that providers will submit accurate claims, not abuse processes or allowablebenefits, and exercise their best independent judgment when deciding which services to orderfor their patients.Our PolicyMagellan has implemented a comprehensive compliance program to ensure ongoingcompliance with all contractual and regulatory requirements. Magellan’s Compliance Programdescribes our comprehensive plan for the prevention, detection and reporting of fraud, waste,abuse, and overpayment across various categories of healthcare-related activities andMagellan Rx Management Provider Manual Page 9
operations. The elements of the Compliance Program include:[I] Written Policies andProcedures; [II] Designation of a Compliance Officer and a Compliance Committee; [III]Conducting Effective Training and Education; [IV] Developing Effective Lines ofCommunication; [V] Auditing and Monitoring; [VI] Enforcement Through Publicized DisciplinaryGuidelines and Policies Dealing With Ineligible Persons; [VII] Responding to Detected Offenses,Developing Corrective Action Initiatives and Reporting to Government Authorities; and [VIII]Whistleblower Protection and Non Retaliation policy.Magellan does not tolerate fraud, waste, or abuse, either by providers or staff. Accordingly, wehave instituted extensive fraud, waste, and abuse programs to combat these problems.Magellan’s programs are wide-ranging and multi-faceted, focusing on prevention, detection,and investigation of all types of fraud, waste, abuse, and o
Magellan Rx Management Provider Manual Page 7 1.0 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
