Provider News - June 2017

REQUIREMENTS: Before November 1, 2017: - Billing team must establish prior authorization workflow with Magellan Rx for all medical pharmacy benefits (specialty medications administered in medical settings). Update billing system to route medical pharmaceutical claims through Magellan Rx for prior auth approval before processing. - Providers and clinical staff must begin submitting medical pharmaceutical requests to Magellan Rx during the transition period; Security Health Plan will provide detailed provider communications and onsite training. - Update encounter templates and order entry systems to flag medical pharmacy benefits requiring Magellan Rx prior authorization. - Communicate new process to all ordering providers and clinical staff to prevent claim denials due to missing prior authorization. Immediately (June 2017): - Billing and clinical teams must review colorectal cancer screening coverage tables by plan type (Medicare Advantage, Medicare MSA, Commercial EPO/HPPN, State of Wisconsin members). Update coverage verification to accurately reflect frequency limits and member cost-sharing obligations. - Front desk and verification staff must verify specific plan type when authorizing colorectal cancer screening referrals (colonoscopy, FIT, FOBT, flexible sigmoidoscopy, FIT-DNA/Cologuard) to determine coverage frequency and member responsibility. - For Commercial EPO/HPPN plans: verify providers and facilities are in-network using www.securityhealth.org/directory or 1-800-472-2363 before authorizing referrals. - Failure to obtain Magellan Rx prior authorization for medical pharmaceuticals after November 1, 2017 will result in claim denials. Claims submitted without proper colorectal screening coverage verification may be denied or subject to unexpected member bills.