Transcript Telephonic Prior Authorizations - Magellan Medicaid Administration

Kentucky Department for Medicaid Services
&
Magellan Medicaid Administration
Kentucky Medicaid
Pharmacy Summer Seminar
September 2010
Agenda
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Website Overview (https://kentucky.fhsc.com)
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Home Page
Contact Information
Providers
 Drug Information
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Preferred Drug List (PDL)
Over the Count Drug List (OTC)
Maximum Quantity Drug List
Email Registration
Manuals
Notices
Prior Authorizations
Remittance Advice
Seminars
Committees
 Pharmacy and Therapeutics Advisory Committee (PTAC)
 Drug Management Review Advisory Board (DMRAB)
Maximum Allowable Cost (MAC)
Epocrates
Members
Recent & Upcoming Changes
Questions
Magellan Medicaid Administration | 2
Website Overview
https://kentucky.fhsc.com
Home Page
Contacts
Contact Information
Contacts
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Technical Call Center (TeCC) – (800) 432-7005
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Claim rejections/denials
 Overrides
 Lock-In
 Early Refills
 Timely Filing
 Claims over $5000.00
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Managed Access Program (MAP)/Prior Authorization – (800) 477-3071
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Request prior authorization
 Questions on a prior authorization request
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Claims Payment / Remittance Advices (835s)
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Provider Operations at (804) 965-7619 or email
[email protected]
Home Page
Preferred Drug List (PDL)
Preferred Drug List (PDL)
New Drug Classes On The PDL
Protein Tyrosine Kinase Inhibitors
Topical Agents for Psoriasis
Progestins for Cachexia
Direct Renin Inhibitors
ICD-9 Codes
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The drug classes listed below may require an ICD-9 code, prerequisite therapy, or both.
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Providers should enter the appropriate ICD-9 code to indicate the patient’s diagnosis when required.
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NCPDP field - 424
Drug classes that have ICD-9 code requirements
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Androgen Hormone Inhibitors
Anticonvulsants: Second Generation
Antihyperkinesis Agents
Antidepressants: SNRIs
Atypical Antipsychotics
Diabetes: DPP-4 Inhibitors
Growth Hormones
Hematological Agents
Hematology; Bleeding Disorders
Laxatives and Cathartics
Multiple Sclerosis Agents
Non-Ergot Dopamine Receptor Agonists
Ophthalmic Antibiotics, Macrolides
Ophthalmic Antibiotics, Quinolone
Pulmonary Hypertension
Sedative Hypnotics
Sympatholytics
Topical Anesthetics
Most Common Claim Denials
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“88” - DUR Reject
“71” - Prescriber not covered
“76” - Plan limitations exceeded
“75” - Prior Authorization Required
“70” - Product/Service not covered
“63” - Service/Product Not Covered for Institutionalized
Patient
 Long Term Care
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“41” - Submit bill to other processor or primary payer
 Medicare
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“65” - Patient is not covered
“40” - Pharmacy not contracted with plan on date of service
“81” - Timely Filing Exceeded
Claim Overrides
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3 Brand Script Limitation
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4 Script Limitation
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LEVEL OF SERVICE = “03”
Pregnancy Copay
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PRIOR AUTHORIZATION TYPE CODE = “08”
Emergency Fills
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PRIOR AUTHORIZATION TYPE CODE = “07”
Coordination of Benefits
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PRIOR AUTHORIZATION TYPE CODE = “05”
NCPDP field 335-2C - “02”
ProDUR
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Therapeutic Duplication (TD)
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Duplicate Ingredient (ID)
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Drug to Drug (DD)
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DUR REASON OF RESULT (Conflict Code) (NCPDP Field #439-E4)
DUR PROFESSIONAL RESULT (Intervention Code) (NCPDP Field #440-E5)
RESULT OF SERVICE (Outcome Code) (NCPDP Field #441-E6)
Providers Tab
Drug Information
Maximum Quantity Drug List
Over-The-Counter (OTC) Drug List
Email Update Registration
Manuals
Pharmacy Provider Manual
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Specific program details
 Drug coverage
 Emergency procedures
 Coordination of benefits
 Medicare drug coverage
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Prospective Drug Utilizations Review (ProDUR)
Edits
Provider Reimbursement
Universal Claim Form
Payer Specs
Long Term Care (LTC)
Supplemental Provider Manual
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Processing LTC
 Identifying members
 Dispensing limits
 Drug coverage
 Prior authorization
 Medicare covered drugs
 Compounds
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Prospective Drug Utilizations Review (ProDUR)
 Reimbursement
Provider Notices
Prior Authorizations
Prior Authorization Forms
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PA Request Form Brand
 Must be completed by the prescriber
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PA Request Form Mental Health
 Atypical Antipsychotic agents only
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PA Request Form Regular
 All other drugs
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PA Request Form Synagis (NEW)
 PA Request Form Suboxone/Subutex (NEW)
 PA Request Form Zyvox (NEW)
Telephonic Prior Authorizations
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Kentucky Medicaid began accepting telephonic prior authorization
requests on 07/01/2010
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Telephonic requests should be directed to (800) 477-3071, 24 hours a
day, 7 days a week
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Requests for products requiring a drug-specific fax form will still need to
be faxed
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Suboxone®/Subutex®
 Zyvox®
 Synagis®
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Brand Name Drug Form
New Prior Authorized Drugs
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Caduet
Lidoderm
Lyrica
Ranexa
Skelaxin
Soma/carisoprodol products
Suboxone/Subutex
 Drug specific PA fax form
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Tussionex/Tussicaps
 Zyvox
 Drug specific PA fax form
Prior Authorization Denials/Appeals
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Only a patient or family member can appeal a prior authorization
denial
 The member has 30 days from receipt of the denial letter to
submit a written appeal
Kentucky Department for Medicaid Services
Division of Administration and Financial Management
Administrative Services Branch, 6W-C
275 East Main Street
Frankfort, KY 40621-0001
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The prescribing physician can attend the appeal hearing and
testify on the patient’s behalf
Remittance Advice
Remittance Advice
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Contacts
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For inquiries related to remittance advices please email requests to
[email protected] or contact Provider Operations at: (804)
965-7619
Forms
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Secure File Transfer Protocol (FTP) Guideline
 Electronic Remittance Advice Agreement
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NonBusiness Associates Confidentiality Agreement
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All forms must be completed
Provider Seminars
Kentucky Medicaid
Committees
Committees Tab
Pharmacy and Therapeutics Advisory Committee
(PTAC)
PTAC
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The Pharmacy and Therapeutics Advisory Committee advises
the Governor, Secretary of the Cabinet for Health and Family
Services and the Commissioner of the Kentucky Department for
Medicaid Services on development and administration of an
outpatient drug formulary
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The committee is comprised of 13 voting members and 2 nonvoting members
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The committee meets 6 times a year
Drug Management Review Advisory Board
(DMRAB)
DMRAB
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The Drug Management Review Advisory Board is comprised of active
health care professionals who meet quarterly to discuss drug utilization
and how that relates to current clinical guidelines and current “best
practices”
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The committee is comprised of 14 voting members and 2 non-voting
members
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The committee meets on a quarterly basis
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As a result of those meetings, patients’ medication profiles are reviewed
by clinical pharmacists to see if they appear to be treated based on
current clinical guidelines or current “best practices”
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If it appears that these patients are not being treated appropriately, those
specific prescribers are targeted for education via lettering
RetroDUR Standard Letter
RetroDUR Response Form
RetroDUR Provider Profiling Letter
Maximum Allowable Cost (MAC)
MAC
 The MAC Program was developed by and is maintained by the Magellan
Medicaid Administration
 The goal is to encourage Kentucky Medicaid Providers to move utilization
toward less expensive, therapeutically equivalent drugs, hence saving
increased funds for Kentucky Medicaid
 The MAC prices that comprise the MAC list are subject to periodic review
and modification by FHS at least monthly
 “As needed” reviews, due to provider appeals or sudden significant market
changes, may be performed between the monthly reviews and adjustments
made if warranted
 If a provider does not think a MAC price is valid, he/she may appeal the
price by completing the MAC price inquiry form
MAC List
MAC List
MAC List Request Form
MAC Price Research Request Form
Epocrates
Epocrates
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Epocrates Rx® is a clinical reference that combines detailed
drug information from Epocrates with the Kentucky Medicaid
formulary
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You can check copayment tiers, prescription drug list
alternatives, and generic alternatives
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Epocrates is free
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Compatible with Palm OS and Pocket PC and/or a personal
computer with access to the Internet
Members Tab
Recent & Upcoming
Changes
Recent Changes
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07/01/2010 – Telephonic Prior Authorization Requests
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08/25/2010 - Early Refill
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Telephonic requests should be directed to (800) 477-3071, 24 hours a day, 7 days a week
Requests for products requiring a drug-specific fax form will still need to be faxed
 Suboxone®/Subutex®
 Zyvox®
 Synagis®
 Brand Name Drug Form
The early refill tolerance was increased from 80% to 90%
The ability to override the Early Refill reject through POS has been eliminated
Pharmacies will need to call the Magellan Medicaid Administration Technical Call Center to
request the override
 (800) 432-7005
09/01/2010 - OTC Product Coverage
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Coverage has been limited to a specified list of OTC products
The list of covered products have been posted to the web at https://kentucky.fhsc.com on the
Providers tab under Drug Information
Products not on this will deny at point-of-sale (POS) with NCPDP rejection of 70; NDC not
covered
Overrides can not be submitted through the POS system or given by a call center
Upcoming Changes
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10/01/2010 – Non-Medicaid Prescribers
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Only prescriptions written by prescribers who are enrolled as a Kentucky
Medicaid Provider will be paid
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Claims will deny with NCPDP rejection 71; Prescriber not covered
 Prescribers can enroll by contacting the Department for Medicaid Services
Provider Enrollment Department
 (877) 838-5085
 10:00 am – 4:30 pm, Monday through Friday
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Applications take approximately 90 days to process
10/01/2010 – Diabetic Supplies
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Diabetic supplies including meters, test strips, lancets, syringes and
needles will be billed through POS or on a Universal Claim Form (UCF)
from pharmacy providers
 A copy of the UCF is located in the pharmacy provider manual