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Idaho Medicaid Pharmacy Program Provider Training Presenter Title/Department Date.

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Presentation on theme: "Idaho Medicaid Pharmacy Program Provider Training Presenter Title/Department Date."— Presentation transcript:

1 Idaho Medicaid Pharmacy Program Provider Training Presenter Title/Department Date

2 Objectives  Upon completion of this training, participants will be able to  Describe changes to pharmacy claims processing implemented on January 30, 2010 by Magellan Medicaid Administration in support of the Idaho Medicaid Program.  List contact numbers that assist in processing pharmacy claims or answer questions regarding claims processing. Magellan Medicaid Administration | 2

3 Magellan Medicaid Administration Proudly presents…. The Idaho Medicaid Pharmacy Program Point-of-Sale (POS) Implementation Magellan Medicaid Administration | 3

4 Idaho Medicaid Pharmacy Program  On Saturday, January 30, 2010, Magellan Medicaid Administration began processing claims for the Idaho Medicaid Pharmacy Program.  Magellan Medicaid Administration performs the following functions:  Claims processing  Operations support for the POS system  Technical support for providers  Education and outreach for providers  Magellan Medicaid Administration’s Idaho Pharmacy Support Center  Magellan Medicaid Administration | 4

5 Idaho Medicaid Pharmacy Program, cont. Clinical Prior Authorizations  For initiating Prior Authorizations (PA), contact the Idaho Department of Health and Welfare (IDHW)  Monday – Friday, 8:00 a.m. – 5:00 p.m. MT  (Local)  (Toll free)  (Fax) Magellan Medicaid Administration | 5

6 About Magellan Medicaid Administration  30+ years of experience serving public sector health care programs  Medicaid  State drug program for seniors  Mental health agencies  Administers more Medicaid pharmacy benefit programs than all the competitors combined  National leader in Medicaid rebate administration  970 employees nationwide  Headquartered in Glen Allen, VA, with offices in over 40 states Magellan Medicaid Administration | 6

7 Provider Electronic Solutions (PES)  If you use the PES software provided by Hewlett-Packard Enterprise Services to submit claims, verify eligibility, or submit claims solely on paper, then you need to send an with “PES” in the subject line to immediately.  These processes changed in January 2010 and IDHW will need to discuss the options that will be available to you.  As of January 30, 2010 you are able to access Web Claims Submission. Magellan Medicaid Administration | 7

8 Online 5.1 Claims Submission  On January 30, 2010, Magellan Medicaid Administration began accepting claims submissions. Magellan Medicaid Administration | 8

9 Plan Effective Date for POS Transition Implementation  On January 29, 2010, the current pharmacy vendor (HP-formally known as EDS) shut down claims processing at 8:00 p.m. MT.  On Saturday, January 30, 2010, Magellan Medicaid Administration began claims processing at 7:00 a.m., PT, 8:00 a.m., MT; 10:00 a.m., ET. Magellan Medicaid Administration | 9

10 Availability  Magellan Medicaid Administration will provide system availability for submitting claims  Daily, 24/7/365  Except  Saturday down at 9:00 p.m., MT  Sunday up at 4:00 a.m., MT Magellan Medicaid Administration | 10

11 Readiness Documents and Resources  Pharmacy Claims Submission Manual  Payer Specification document  User Administration Console User Guide  Web Claims Submission User Guide  All documents and resources will be located on the following website:  https://idaho.fhsc.com https://idaho.fhsc.com *This site became available on January 4, 2010 Magellan Medicaid Administration | 11

12 Modes of Claim Submission  POS Claims Submission  Batch Claims (National Council on Prescription Drug Programs (NCPDP) Batch 1.1 FTP)  Web Claims Submission  Provider Submitted Paper Universal Claim Form (this is a change) Magellan Medicaid Administration | 12

13 POS Technical Readiness Magellan Medicaid Administration | 13

14 Technical POS Submission Readiness  Ensure your software vendors are certified to send NCPDP 5.1 (most vendors are already certified).  For questions, contact Dorothea Roane at  Ensure that the routing information  Banking Identification Number (BIN)  Processor Control Number (PCN) are changed Magellan Medicaid Administration | 14

15 Necessary Data Elements for Initial Set-Up  All transactions require the following:  Version/Release#5.1  BIN Number*  Processor Control #*P  Group ID*IDMEDICAID  Software Vendor/Certification ID: Assigned when vendor is certified with Magellan Medicaid Administration.  Claims will reject if the new data elements (denoted with asterisks) are missing and if versions other than NCPDP 5.1 are used. Magellan Medicaid Administration | 15

16 Additional Necessary Data Elements for Initial Set-Up On Claim Segment  Number of Refills will be a required field.  Prescription Origin Code will be a required field. This field is used as a mechanism for providers to validate that written prescriptions have been submitted in accordance with tamper resistant guidelines. On Patient Segment  Pregnancy Indicator will be a new field that will be populated with a value of  Blank = Not Specified  “1” = Not Pregnant  “2” = Pregnant Magellan Medicaid Administration | 16

17 Additional Necessary Data Elements for Initial Set-Up, cont. On Clinical Segment  Diagnosis Code Count will be a required field when submitting diagnosis information on the claim.  Diagnosis Code Qualifier will be a required field when submitting diagnosis information on the claim.  Diagnosis Code will be a required field when submitting diagnosis information on the claim.  These fields are required for all hospice patient claims. Magellan Medicaid Administration | 17

18 Client Eligibility Determination  For participant eligibility determination, Magellan Medicaid Administration matches on  Patient first name = First 3 bytes  Patient last name = First 5 bytes Magellan Medicaid Administration | 18

19 Claims Submission Timely Filing Limits  Date Rx Written = should be the original date the prescription was written  Date of Service = should be the actual DOS  The Date Rx Written is used as a factor in refill editing logic Magellan Medicaid Administration | 19

20 Claims Submission Timely Filing Limits, cont.  POS claims are generally submitted at the time of dispensing. If a claim is submitted after a drug is dispensed due to mitigating circumstances the following guidelines apply:  For all original claims, the timely filing limit from the Date of Service (DOS) is 366 days.  For all reversals, the timely filing limit from the DOS is Unlimited.  For all rebill claims, the timely filing limit from the DOS is 732 days.  For all paper claims, it will be 365 days from date written.  Claims that exceed the timely filing limit will deny with the NCPDP Error Code 81, “Timely Filing Exceeded.” Providers may request an override following IDHW guidelines. This edit uses the Adjudication Date and Date of Service. Magellan Medicaid Administration | 20

21 Date Rx Written to Date of Service Edits  Claims that exceed the maximum Date Rx Written to Date of Service limit as indicated below will deny with NCPDP Error Code M4/“Prescription number/time limit exceeded.” This edit uses the Date Rx Written and the Date of Service.  Date Rx Written to First Fill Date = 366 days from the date written for non- controlled drugs.  Date Rx Written to First Fill Date = 183 days from date written for CIII, CIV, and CV drugs.  Date Rx Written to First Fill Date = 90 days from date written for CII drugs.  Date Rx Written to Refill Limit Durations for Controlled Substances = 183 days from date written for CIII, CIV, and CV drugs. Magellan Medicaid Administration | 21

22  All submitted fields will be edited for valid format.  All submitted fields will be edited for valid values.  If you send optional data, the values must be valid and any supporting/associated fields must be sent. NCPDP 5.1 Magellan Medicaid Administration | 22

23 NCPDP 5.1, cont.  The following transactions will be accepted and processed Claim Type Original ClaimsB1 ReversalsB2 RebillsB3 EligibilityE1 Magellan Medicaid Administration | 23

24 NCPDP 5.1, cont.  HIPAA Compliance: there are requirements for privacy regulations regarding the use of claim data elements.  Data element conditions are detailed in the Payer Specification Sheet, including  Mandatory (NCPDP designation – required at all times)  Situational (NCPDP designation – required in specific circumstances)  Other (Repeating, Not Supported, and Not Used) Magellan Medicaid Administration | 24

25 NCPDP 5.1, cont.  In NCPDP 5.1, data is grouped together in segments.  Designated segments are needed to support specified transactions.  Refer to the Payer Specifications Sheet for identification of all required segments.  For the most current version, always check the website:  https://idaho.fhsc.com https://idaho.fhsc.com Magellan Medicaid Administration | 25

26 Example: Payer Specification Segment Detail Magellan Medicaid Administration | 26

27 Dispensing Limitations – Days Supply  34-day supply per Rx maximum.  Exceptions: Maintenance List cannot exceed 100 day supply.  Maintenance List –Cardiac Glycosides –Thyroid Replacement hormones –Prenatal Vitamins –Nitroglycerin Products, oral or sublingual –Fluoride and vitamin/fluoride combination products –Non-legend oral iron salts –Oral Contraceptives Magellan Medicaid Administration | 27

28 Dispensing Limitations – Refills  DEA = 0: original + up to 99 refills within 366 days from original Date Rx Written  DEA = II: No refills  DEA = III–V: original + 5 refills within 183 days from original Date Rx Written Magellan Medicaid Administration | 28

29 Dispensing Limitations  Number of Refills Authorized  Magellan Medicaid Administration’s POS logic uses this to validate on refill status.  New for claims submission on January 30,  Values  0-99 Magellan Medicaid Administration | 29

30 Early Refills  Early refills tolerance periods  Tolerance = 75 percent for all products  NCPDP Error Code “88” will display for an early refill  If the drug is a controlled substance, the IDHW Pharmacy Unit will handle all overrides. Magellan Medicaid Administration | 30

31 Early Refills, cont.  For initiating prior authorizations, contact IDHW Monday – Friday, 8:00 a.m. – 5:00 p.m., MT  (Local)  (Toll free)  (Fax) Magellan Medicaid Administration | 31

32 Unit of Measure  Unit of Measure  EA = Each  GM = Grams  ML = Milliliters  NCPDP Field #  If you are submitting a paper claim, please write this in on the Universal Claim form. Magellan Medicaid Administration | 32

33 Durable Medical Equipment (DME)  Magellan Medicaid Administration will not be processing DME claims.  For questions about DME or Nutritional Supplements and DME PA Requests contact the DME Specialist at:  (Toll free)  (Fax) or  (Fax)  Hours are 8:00 a.m. – 5:00 p.m. MT Monday – Friday  PES claims are still accepted for DME products. Magellan Medicaid Administration | 33

34 Coordination of Benefits (COB)  Providers are required to fully pursue all third-party coverage before billing Medicaid.  Providers must comply with all policies of a patient’s insurance coverage, including, but not limited to, prior authorization, quantity, and days supply limits.  Magellan Medicaid Administration will assist IDHW in monitoring this process for compliance on all claims. Magellan Medicaid Administration | 34

35 Coordination of Benefits On Pricing Segment  Patient Paid Amount Submitted will be a required field when submitting an Other Coverage Code (OCC) of a “2.” The claim will reject if it is not submitted with the OCC of a “2” or submitted on claims where OCC is NOT equal to a “2.” On COB Segment  Other Payer Reject Count will be a required field when submitting an OCC of a “3.”  Other Payer Reject Code will be a required field when submitting an OCC of a “3.” Magellan Medicaid Administration | 35

36 Member Lock-In Members can be locked into  A pharmacy  A pharmacy and physician(s)  Specific drug by a specific physician Magellan Medicaid Administration | 36

37 Emergency Override Procedure  Medicaid will pay for a 72-hour emergency supply of medications that require a PA if the doctor has not submitted a prior authorization request and it is after hours, a weekend, or a IDHW designated holiday.  The appropriate PA process must be utilized during regular business hours. All of the following conditions must be met for an emergency supply:  The cardholder is Medicaid eligible on the date of service.  The prescription is new to the pharmacy.  The medication requires PA.  The days supply for the emergency period does not exceed three days. Magellan Medicaid Administration | 37

38 Emergency Override Procedure  The override codes for billing for a 72-hour emergency supply are  DUR REASON FOR SERVICE (NCPDP Field # 439-E4):TP (Payer/processor question)  DUR PROFESSIONAL SERVICE (NCPDP Field # 440-E5): MR (Medication review)  DUR RESULT OF SERVICE (NCPDP Field # 441-E6) 1F (Filled, with different quantity)  In order for the cardholder to get the remainder of their fills or subsequent refills, a completed PA request must be faxed to the Medicaid Pharmacy Unit at (Local). Magellan Medicaid Administration | 38

39 Compound Processing  Compounds are processed using the Multi-Ingredient Compound functionality as provided by NCPDP 5.1.  All compounds must contain at least two ingredients, and at least one ingredient must be a covered product.  If total cost is not equal to the sum of the ingredients’ cost, the claim will deny.  Single ingredient compound claims are not accepted. Magellan Medicaid Administration | 39

40 Compound Processing, cont.  Submission Clarification Code (SCC) = 8 may be submitted at POS to override and pay only covered ingredients within the compound. SCC = 8 does not override obsolete date of drug or existing PA requirements.  Multiple instances of a National Drug Code (NDC) within a compound will not be allowed.  Dispense fee for compounds is the standard dispense fee with additional amounts added based on the Route of Administration.  If the claim rejects for a non-covered drug, the NCPDP Error Code 70-NDC Not Covered, will be returned. Magellan Medicaid Administration | 40

41 Fields Required for Submitting Multi- Ingredient Compounds On Claim Segment  Enter COMPOUND CODE (NCPDP Field # 406-D6) of “2”  Enter PRODUCT CODE/NDC (NCPDP Field # 407-D7) as “ ” in the claim segment to identify the claim as a multi- ingredient compound  Enter QUANTITY DISPENSED (NCPDP Field # 442-E7) of entire product  SUBMISSION CLARIFICATION CODE (NCPDP Field #420-DK)  Value “8” should only be used for compounds with both covered and non- covered ingredients. This value allows the provider to be reimbursed for covered ingredients only. This field is not available on the Universal Claim Form (UCF) used for paper claim submission. Magellan Medicaid Administration | 41

42 Fields Required for Submitting Multi- Ingredient Compounds, cont. On Pricing Segment  Enter GROSS AMOUNT DUE (NCPDP Field # 430-DU) for entire product (this is required when entering SCC of “8”) On Compound Segment  COMPOUND DOSAGE FORM DESCRIPTION CODE (NCPDP # 450- EF)  COMPOUND DISPENSING UNIT FORM INDICATOR (NCPDP # 451- EG)  COMPOUND ROUTE OF ADMINISTRATION (NCPDP # 452-EH)  COMPOUND INGREDIENT COMPONENT COUNT (NCPDP # 447- EC) (Maximum of 25) Magellan Medicaid Administration | 42

43 Fields Required for Submitting Multi- Ingredient Compounds, cont. For Each Line Item  COMPOUND PRODUCT ID QUALIFIER (NCPDP Field # 488-RE) of “3” (NDC)  COMPOUND PRODUCT ID (NCPDP Field # 489-TE)  Product ID = NDC  COMPOUND INGREDIENT QUANTITY (NCPDP # 448-ED)  COMPOUND INGREDIENT DRUG COST (NCPDP # 449-EE) Magellan Medicaid Administration | 43

44 Summary of Changes  BIN Number:  Processor Control #: P  Group ID: IDMEDICAID  Software/Vendor Certification: TBD  Pregnancy Indicator  Blank = Not Specified  “1” = Not Pregnant  “2” = Pregnant  Number of Refills Authorized is Required Magellan Medicaid Administration | 44

45 Summary of Changes, cont.  Prescription Origin code is Required  0 = Not Specified  1 = Written  2 = Telephone  3 = Electronic  4 = Facsimile Magellan Medicaid Administration | 45

46 Summary of Changes, cont. On Pricing Segment  Patient Paid Amount Submitted is a required field when submitting an OCC of a “2.” The claim will reject if it is not submitted with the OCC of a “2” or submitted on claims where OCC is NOT equal to a “2.”  Patient Paid Amount Submitted must be greater than $0.00 on a POS claim with an OCC of a “2.” On COB Segment  Other Payer Reject Count is a required field when submitting an OCC of a “3.”  Other Payer Reject Code is a required field when submitting an OCC of a “3.” Magellan Medicaid Administration | 46

47 Summary of Changes, cont. On Clinical Segment  Diagnosis Code Count is a required field when submitting diagnosis information on the claim  Diagnosis Code Qualifier is a required field when submitting diagnosis information on the claim  Diagnosis Code is a required field when submitting diagnosis information on the claim  These fields are required on all Hospice claims Magellan Medicaid Administration | 47

48 Contact Information  Idaho Medicaid Eligibility (Magellan Medicaid Administration)  (Toll free)  24/7/365  For initiating prior authorizations contact IDHW Monday – Friday, 8:00 a.m. – 5:00 p.m. MT  (Local)  (Toll free)  (Fax)  Paper Claims Mailing Address Magellan Medicaid Administration, Inc. Post Office Box Richmond, VA Magellan Medicaid Administration | 48

49 Contact Information, cont.  Magellan Medicaid Administration’s Idaho Pharmacy Support Center Line  24/7/365  (Toll free)  Magellan Medicaid Administration’s Web Support Help Desk  6:00 a.m. – 6:00 p.m. MT, Monday – Friday  (Toll free)  The Web Support Help Desk can assist you with navigation, password management, and general questions. Magellan Medicaid Administration | 49

50 Contact Information, cont.  If you have questions regarding the Idaho Medicaid Management Information System (MMIS) transition, send an to: or visit the website at:  If you have questions regarding Provider Record Update, call Unisys at or Unisys at Magellan Medicaid Administration | 50

51 Important Websites   (Participants and Providers)   https://idaho.fhsc.com https://idaho.fhsc.com  https://www.fhsc.com/reference https://www.fhsc.com/reference   Magellan Medicaid Administration | 51

52 https://idaho.fhsc.com  Source of Idaho Medicaid Pharmacy Program information and resources  Forms (PA, Medical Necessity, Provider Lock-in Agreement)  Manuals  Provider Payer Specifications  Provider communication (letters, notices, etc.)  Web tools reference collection  Web Claims Submission Portal  Web PA Submission Portal  Contact Information  Lists (SMAC, PDL, etc.) Magellan Medicaid Administration | 52

53 https://idaho.fhsc.com Magellan Medicaid Administration | 53

54 Provider Web Tools  Web Claims Submission  Providers wishing to access Web Claims Submission must register via the UAC.  The user name and password established through UAC registration provides access to all Web tools.  Instructional resources for provider Web tools and UAC registration are located on  https://idaho.fhsc.com https://idaho.fhsc.com  Magellan Medicaid Administration | 54

55 UAC Registration  Go to https://idaho.fhsc.comhttps://idaho.fhsc.com  Click on the UAC link located on the upper right-hand side of the homepage. Magellan Medicaid Administration | 55

56 Step 1 – Obtaining a PIN 1.Click on the I do NOT have a User ID and need to initiate or complete registration to become a Delegated Administrator radio button and then click the Continue button. Magellan Medicaid Administration | 56

57 Step 1 – Obtaining a PIN, cont. 2.Click on the Request Pin tab. Enter your name and phone number, then click the Continue button. 3.On the next screen under the Request Pin tab, select an Organization Type (Org Type), a State, and an Organization ID Type (Org ID Type), enter the Organization ID (Org ID), and click Validate Org ID. A letter with a PIN number will be sent to each of the organizations you submitted. Please note which Org ID Type is used for the PIN request. PIN letters will be mailed via United States Postal Service. Magellan Medicaid Administration | 57

58 Step 2 – Registering with Your PIN 1.When the PIN letter is received, return to this application, and from the Who Are You? screen, select I do NOT have a User ID and need to initiate or complete registration to become a Delegated Administrator and click Continue. 2.Select the Register w/Pin tab, and enter the required information, then click the Continue button. 3.Select an Organization Type (Org Type), a State, and an Organization ID Type (Org ID Type), enter the Organization ID (Org ID) and PIN number, then click Validate Org ID. Continue entering and validating as many Organization IDs and PIN numbers as necessary, then click the Submit button. An containing an activation link will be sent to the address entered. After you click on the activation link, a confirmation screen will appear in your browser window letting you know that you have been successfully added to our directory. Magellan Medicaid Administration | 58

59 Web Claims Submission  The Web Claims Submission tool is a state-specific secure website that gives pharmacies the ability to  Enter a claim  Enter a claim reversal  Enter a rebill  Check a client’s eligibility  Search for previously submitted claims via the Web Claims Submission application Magellan Medicaid Administration | 59

60 Accessing the Web Claims Submission Tool  Go to https://idaho.fhsc.com.https://idaho.fhsc.com  Click on the Web Claims Submission link under the Provider tab.  Enter your Username and Password established through UAC and click Go. Magellan Medicaid Administration | 60

61 Entering a Claim 1.From the Service Provider List page, select the Provider ID from the drop-down menu. 2.Click the Select button to view the Adjudicated Search page. Magellan Medicaid Administration | 61

62 Entering a Claim, cont. 3.Click the ID_Web_Claim_51 template from the listing to view the Claims Submission Entry page. Magellan Medicaid Administration | 62

63 Entering a Claim, cont.  The Claim Entry template has both optional and required fields.  Noneditable fields are unavailable (grayed) and cannot be populated.  Mandatory or required fields are noted with a red asterisk following the field name.  To submit a completed claim form, click the Submit button. Magellan Medicaid Administration | 63

64 Entering a Claim, cont. Magellan Medicaid Administration | 64

65 Claim Submission Response Magellan Medicaid Administration | 65

66 Searching for a Claim  To Search for a claim 1.Enter the Cardholder ID 2.Enter the Date of Service or click the Calendar icon to select the date 3.Click the Search button to view the Adjudicated Claims Search Results page Magellan Medicaid Administration | 66

67 Claim Search Results 1.To reverse the claim, click on the Reverse hyperlink. The Reverse template will display with the claims information filled in based on the original claim submitted. 2.To resubmit the claim, click on the Resubmit hyperlink. The Rebill template will display with the claims information filled in based on the original claim submitted. You can update the fields and then resubmit the claim. Magellan Medicaid Administration | 67

68 Web PA  Web PA is a tool that prescribers can utilize to submit prior authorizations for patients.  It is accessed by Delegated Administrators through UAC.  Web PA is one of three ways a prescriber can submit prior authorizations.  Other methods include  Phone  Fax Magellan Medicaid Administration | 68

69 Magellan Medicaid Administration | 69


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