Provider News - November 2017

REQUIREMENTS: (1) By Nov 1, 2017: Billing team must implement Magellan Rx prior authorization program for medications listed at www.securityhealth.org/rxpa. Update billing workflows to require PA submission before claim processing. Contact Provider Relations at 1-800-548-1224 for implementation support. Failure to obtain prior auth will result in claim denials. (2) By Jan 1, 2018: Billing team must transition all pharmacy claims processing from current PBM to MedImpact Healthcare Systems. Update billing system configuration, pharmacy network files, and claim submission processes. Contact Pharmacy Services at 1-877-873-5611 or 715-221-9604 for transition details. Claims submitted to wrong PBM will be delayed or denied. (3) Immediately: Update prior authorization requirements in billing system and provider encounter forms to include: cardiac valve replacement, femoro-acetabular surgery for hip impingement syndrome, MAZE procedures, and skin substitutes. Reference www.securityhealth.org/priorauthorizations for complete list. All providers must obtain prior auth for these procedures before scheduling/billing or claims will be denied. (4) For admissions on/after Sept 1, 2017: Billing/clinical team must use Interqual 2017 guidelines for medical necessity review of inpatient medical and behavioral health admissions. Update any internal authorization tools or criteria references. (5) All billing staff: Review updated Provider Manual at www.securityhealth.org/providermanual for new interface and information structure to reduce claim processing delays.