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PharmacyProvider ManualRevised: June 2020Pharmacy Provider Manual1
Table of Contentsintroduction And Contact Information.5Contact Information.5General Information.6Envolve Pharmacy Solutions Provider Services Call Center.6Envolve Pharmacy Solutions Prior Authorization Help Desk.6Envolve Pharmacy Solutions Pharmacy Claim Submission.6Pharmacy Network Participation. 7Provider Enrollment and Participation.7Pharmacy Credentialing Application.7Credentialing Standards.8Licensure.8Insurance.8Drug Enforcement Agency Controlled Substance Registration Certificate.8Medicaid Provider Number. 9Changes in Documentation and Other Information. 9Ownership or Control Changes of Network Provider. 9Network Participation. 9Pharmacy’s Affiliation with PSAO/TPA. 9Update Information with NCPDP. 9Advertising and Promotions. 10Office of Inspector General. 10Reporting of Investigations and Disciplinary Actions. 10Confidentiality and Proprietary Rights. 10Court Orders, Subpoenas, or Governmental Requests. 11No Cause Termination. 11Termination for Breach. 11Immediate Suspension or Termination. 11Network Termination. 11Effect of Termination.12Dispute Resolution.12Quality and Safety Criteria Monitoring.12Provider Services and Standards; Pharmacy Claim Submission.13Eligibility Verification.13Professional Judgment.132 2020 Envolve Pharmacy Solutions
Nondiscrimination.13Identification Cards.13Eligible Plan Member Fees. 14Collection of Eligible Plan Member Pay Amounts. 14Payer of Last Resort. 14Limitation on Collection. 14Refills. 14Submitting a Claim. 14Claim Definition. 15Clean Claim Definition. 15Non-Clean Claim Definition. 15Partial Fill. 15Filing/Reversing a Claim. 15Rejected Claims. 15Data Fields and Submission Requirements. 15Online System Down-Time Transmission Procedures. 16Prescription Origin Code. 16Taxes. 16Submitting Compounds. 16Payment Guidelines.17Claim Payment.17Electronic Funds Transfer (EFT).17Claims Payment/Remittance Advice.17Disputed Claims.17MAC Pricing Issues. 18Pricing Changes. 18Pricing Benchmark. 18Rebates. 18Clinical Pharmacy Programs and Services. 19Provider Information Updates. 19Directories. 19Performance Initiatives. 19Educational Materials. 19Generic Drug Standards. 19DAW Codes and Descriptions.20Pharmacy Provider Manual3
Drug Utilization Review. 21Formularies. 22Prior Authorization. 23Drug Alert and Recall. 23Member Rights and Responsibilities.24Provider Complaint and Grievance Process. 26Provider Complaint and Grievance Process.26Eligible Plan Member Complaint and Grievance Process. 27Pharmacy Audit Standards. 28Inspections Rights.28Audit Types.28Pharmacy Identification for Audit.28Common Claim Errors Resulting in Audits.28Desktop Audits.29Claim Check Audits.30Documents and Records Access.30Prescription Requirements.31Signature Log. 32Audit Resolution. 32Medicare Claims. 33Medicare pharmacy claims. 33Medicare Part B vs. Part D billing. 33Envolve Pharmacy Solutions Processing of Medicare Drug Exclusions.34Medicare Vaccine Administration.34Drugs Covered under Part D for a Beneficiary Who Has Elected Hospice.34Medicare Coverage Determinations.34Exceptions to plan coverage for Medicare members. 35Envolve Pharmacy Solutions Pharmacy Compliance. 35Medicare Prescription Drug Coverage and Your Rights.36Frequently Asked Questions by Provider. 37APPENDIX A – Regulatory Addenda. 39APPENDIX B – Discrepancy List. 734 2020 Envolve Pharmacy Solutions
Introduction and Contact InformationEnvolve Pharmacy Solutions is a pharmacy benefit manager (PBM) headquartered in Fresno, California. We provide pharmacybenefit design, administration, and management services as well as a sophisticated, state-of-the-art claims processing systemto plan sponsors. Programs such as Drug Utilization Review (DUR), clinically based formularies, generic substitution, anddisease-oriented managed care allow third-party payers to effectively manage the cost of providing prescription benefits fortheir members.Envolve Pharmacy Solutions is a wholly owned subsidiary of CenCorp Health Solutions (CenCorp), a subsidiary of CenteneCorporation (Centene).With corporate headquarters in St. Louis, Missouri, Centene Corporation (Centene), a Fortune 500 Company, is a leading,multi-line healthcare enterprise that provides programs and related services to the rising number of under-insured anduninsured individuals. Many of these individuals receive benefits provided under Medicaid, including the Children’s HealthInsurance Program (CHIP), as well as Aged, Blind or Disabled (ABD), Foster Care and long-term care, in addition to other statesponsored programs, and Medicare (Special Needs Plans). Centene’s CeltiCare subsidiary offers states unique “exchangebased” and other cost-effective coverage solutions for low-income populations. The Company operates local health plans andoffers a range of health insurance solutions. It also contracts with other healthcare and commercial organizations to providespecialty services including behavioral health, life and health management, managed vision, telehealth services, and pharmacybenefits management.Contact InformationFor questions, submission of suggestions or other information regarding information in the Envolve Pharmacy SolutionsPharmacy Provider Manual, please send inquiries to the following:Envolve Pharmacy Solutions, Inc.Attn: Chief Operating Officer5 River Park Place East, Suite 210Fresno, CA 93720Pharmacy Provider Manual5
General InformationInformation in the Envolve Pharmacy Solutions Provider Manual is considered proprietary and intended for use only by providerscredentialed in the Envolve Pharmacy Solutions Pharmacy Network. Providers cannot copy, reproduce, distribute or shareinformation included in this provider manual except as authorized by provider agreement.Envolve Pharmacy Solutions Provider Services Call CenterThe Envolve Pharmacy Solutions Provider Services Call Center is staffed with Customer Service Representatives during thefoll
The Medicaid Provider Number must be kept current at all times. Once credentialed to participate in the Envolve Pharmacy Solutions Pharmacy Network, the provider must notify Envolve Pharmacy Solutions immediately in writing if its Medicaid Provider Number is canc
