Medical Injectables Program

Transcription

1 Medical Injectables Program Quick Reference Guide HorizonBlue.com

2 Table of Contents Introduction... 3 Contact Magellan Rx Management... 3 Medical Injectables MNAR List... 4 Basic Information Required for MNAR Determination... 4 Determination Time Frames... 4 MNAR Denials and Appeals... 5 Access the Magellan Rx Management Website... 5 Member Eligibility & Benefits

3 Introduction Horizon Blue Cross Blue Shield of New Jersey collaborates with Magellan Rx Management (formerly ICORE Healthcare, LLC), a specialty pharmaceutical management company to administer our Medical Injectables Program (MIP). Magellan Rx Management (MRxM) conducts medical necessity and appropriateness reviews (MNARs) for specific injectable medications when administered: At a freestanding or hospital-based dialysis center In an outpatient facility In a patient s home* In a physician s office Injectable medications administered during an inpatient stay or in an Emergency Room (ER) do not require an MNAR from MRxM. Obtaining a pre-service MNAR helps expedite claims processing. If an MNAR for these medications is not obtained prior to administration, payment for your claims will be delayed or denied pending receipt of the information needed to determine medical necessity. Contact Magellan Rx Management Ordering and rendering health care professionals and facilities may submit a request for an MNAR by: Visiting the MRxM website at icorehealthcare.com and then clicking the Providers and Physicians icon (for non-urgent requests from participating professionals and facilities), or; Calling MRxM at for all requests including nonparticipating providers and urgent requests Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time (ET). Representatives are also available after hours and on weekends to receive urgent requests**. *Note: For medical injectable services rendered in the patient s home, please call to locate a participating Horizon Care@Home provider and to obtain pre-service determination. **The definition of an urgent request is one in which using the standard MNAR process could seriously jeopardize the life or health of the member, or the ability of the member to regain maximum function, or in the opinion of the provider would subject the member to severe pain that cannot be adequately managed without the medical pharmaceutical treatment being requested. 3

4 Medical Injectables MNAR List MRxM conducts an MNAR determination for the identified injectable medications based on Horizon BCBSNJ medical policy criteria and guidelines. Ordering and rendering health care professionals and facilities are encouraged to obtain a determination for these medications prior to administration. View our complete list of medications, go to HorizonBlue.com/Providers and select Medical Injectables Program under the Products & Programs tab. You may also view the Horizon BCBSNJ Medical Policy Manual at To confirm the status of an MNAR, facilities may visit icorehealthcare.com or call MRxM at Basic Information Required for MNAR Determination To streamline the MNAR process, ordering providers are required to have the following information available when contacting MRxM for all requests: Ordering provider name, address and office telephone and fax numbers Rendering provider name, address and office telephone and fax numbers (if different from ordering provider) Member name, date of birth, gender and Horizon BCBSNJ member identification number Member height, weight and/or body surface area Anticipated start date of treatment (if known) Requested injectable medication(s) Dosing information and frequency Diagnosis and disease state severity Prior therapeutic failures (if applicable) Concomitant medications Additional information may be required depending on the injectable medication. For more specific criteria, please review our Reference Sheets by visiting HorizonBlue.com/Providers. Select Medical Injectables Program under the Products & Programs tab, and then select Reference Sheets. Determination Time Frames Once all required information is provided, a determination can be issued. The request may be delayed if additional clinical documentation is required. Non-urgent requests will be completed as soon as possible based on the medical urgency of the case, but in no more than three business days of receiving all necessary information. Urgent requests will be completed within 24 hours. 4

5 MNAR Denials and Appeals MRxM will issue a letter for all adverse decisions of requests for MNAR. For appeals related to MNAR denials, please follow the appeal instructions supplied within the denial letter. Access the Magellan Rx Management Website Please visit the MRxM website at icorehealthcare.com and: 1. Click on the Providers and Physicians link from the Quick Links box in the lower right of the MRxM homepage. 2. Select New User Request Access from the yellow Sign In area at the top right of the page. 3. Use the Contact link to submit your request. Please have the following information ready: Provider/facility name Provider/facility service site address Tax ID Number (TIN) Health plan Requestor name Requestor address 4. Complete the required fields noted with a red asterisk (*) and any additional information in the text box. 5. Click Submit. Please allow up to two business days for user name and password confirmation. Your administrator will be able to set up user names for designated staff members. Please note the MRxM website cannot be used for retrospective or urgent requests. Those requests must be processed directly through the MRxM call center at If there are any questions about how to use this website, please MRxM at ISDS@magellanhealth.com. You will receive a response within two business days of your request. VIII. Member Eligibility & Benefits Questions related to eligibility, benefits and/or claims should be directed to Horizon BCBSNJ: Physician Services Facility Centralized Service Center Member Services BLUE (2583) or the number listed on the back of the Horizon BCBSNJ member ID card 5