Connecticut AIDS Drug Assistance Program (CADAP) Provider Training

OCTOBER 2018

Overview

• The Connecticut AIDS Drug Assistance Program (CADAP) provides eligible low-income residents with essential medications for the treatment of HIV, related conditions, and other co-morbidities, as well as health insurance premium assistance.

• On November 1, 2018, Magellan Rx Management will start serving members/clients of CADAP.

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Availability

− Daily; 24 hours availability− Exception:

• Saturday at 11:00 p.m., ET through Sunday at 6:00 a.m., ET

• Downtime will only occur if a need exists for maintenance. If not, the system will remain available for claims processing.

• When regularly scheduled downtime does occur, only the amount of time needed for the upgrades or maintenance is utilized and then FirstRx℠ is made available to continue claims processing.

• If the regularly scheduled downtime needs to incorporate a major change to the system, such as a quarterly release enhancement that will take longer than an hour, CADAP Account Management will notify providers in advance of the implementation.

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• CADAP will provide system availability for submitting claims:

Readiness Documents and Resources

• Find a Pharmacy

• Formulary information

• Important Forms

• Links to helpful websites

• All documents and resources will be available on the following website: https://ctdph.magellanrx.com/

• To obtain more information about CADAP visit: https://portal.ct.gov/DSS/Health-And-Home-Care/CADAP/Connecticut-AIDS-Drug-Assistance-Program-CADAP

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Modes of Claims Submission

• Mandatory Point-of-Sale (POS) claims submission

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POS Technical Readiness

Technical POS Submission Readiness

• Ensure software vendors are certified to send National Council for Prescription Drug Programs (NCPDP) D.0

− For questions regarding submitting test claims prior to the implementation date, contact:

−Girija Karri at 1-804-548-0428; (Gkarri@magellanhealth.com)

• Ensure that the routing information is changed:

− Banking Identification Number (BIN)

− Processor Control Number (PCN)

−GROUP ID

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Necessary Data Elements for Initial Setup

• Transaction Header Segment

−All transactions require the following segments:

− BIN Number: 018786

−Version/Release #: D.0

− Processor Control #:

• ADAP Medicare: CTTROOP

• ADAP Non-Medicare: CT

−Group ID:

• RX282327

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Additional Necessary Data Elements for Initial Set-Up

• Unit of Measure (Field 600-28)

−Values:

− EA = Each

−GM = Grams

−ML = Milliliters

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POS Operational Readiness

Claims Submission Timely Filing Limits

• Reminder:

−Date Rx Written should be the original date written

−Date of Service (DOS) should be the actual DOS

− The “Date Rx Written” is used as a factor in refill editing logic

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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 DOS is 366 days.

− For all reversals, the timely filing limit from the DOS is unlimited.

− For all re-bill claims, the timely filing limit from the DOS is 366 days.

− Claims that exceed the timely filing limit will deny with NCPDP Error 81, “Timely Filing Exceeded.”

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NCPDP D.0

• The following transactions will be processed on November 1, 2018:

− Claim Type

− B1: Original Claims

− B2: Reversals

− B3: Re-bills

• For claims with Date of Service prior to 11/1/18, submit reversals and re-bills to DXC.

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NCPDP D.0, 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) or

− Required

−Qualified Requirement

− “Required when”

• 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.

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Coordination of Benefits

• CADAP is always the payer of last resort. Providers must bill all other payers first and then bill CADAP.

• Providers must comply with all policies of a client’s insurance coverage, including, but not limited to prior authorization (PA), quantity, and days’ supply limits.

• Reimbursement will be calculated to pay the lesser of the CADAP or the Other Payer Patient Responsibility as reported by the primary carrier, less than the third-party payment.

• Co-payments will also be deducted for clients subject to the CADAP co-pay. In some cases, this may result in the claim billed to CADAP being paid at $0.00.

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Coordination of Benefits for Medicare Part D Members

• CADAP will pay Medicare Part D medication deductibles and co-payments up to a specific amount set by CMS.

• Any claims submitted over the CMS specific amount will result in a denied claim.

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In Summary

• Timely Filing is 366 days from Date of Service on original and rebilled claims, unlimited for reversed claims

• BIN Number: 018786

• Version/Release #: D.0

• Processor Control #:− ADAP Medicare: CTTROOP− ADAP Non-Medicare: CT

• Group ID: RX282327

• Unit of Measure is Mandatory

• All submitted fields will be edited for valid format and values

• CADAP is the payer of last resort

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POS Claims Processing

Dispensing Policy

• All drugs are to be dispensed with a maximum 30-day supply.

• Exceptions: clients in CADAP with Private Insurance that requires a 90-day supply of the medication.

• There is an annual maximum fill of 13 fills per prescription.

• All CADAP prescriptions must be reauthorized by the prescriber every six months. The claims adjudication system will accept five as the maximum number of refills.

• Dispensing a brand drug when a generic is available does not require a DAW equal to ‘1’.

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Prospective Drug Utilization (ProDUR)

• Claims will deny for an Early Refill with NCPDP Error Code 88 DUR Reject if the following scenario is met:

−All medications – more than 7% of the medication remains based on previous paid claims DOS

− If the days supply is under 15 days, it is 15%

− Period of review is 180 days

− Contact Magellan Rx Management for an override

• Pharmacy providers are allowed to override Drug to Drug, Therapeutic Duplication, Duplicate Ingredient, High Dose, Drug to Pregnancy, Drug to Gender, and Duration of Therapy Limits denials.

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Contact Information

• CADAP Pharmacy Support Center

− Phone: 1-800-424-3310, Option 8, then Option 1

− Fax: 1-800-424-7642

− 24 hours a day, 7 days a week

• CADAP Provider Network & Check Write Services

− Phone: 1-800-441-6001,Option 5

• CADAP Member (Client) Help Desk

− Phone: 1-800-424-3310, Option 8, then Option 3

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Questions and Answers

Legal

This presentation may include material non-public information about Magellan Health, Inc. (“Magellan” or the “Company”). By receipt of this presentation each recipient acknowledges that it is aware that the United States securities laws prohibit any person or entity in possession of material non-public information about a company or its affiliates from purchasing or selling securities of such company or from the communication of such information to any other person under circumstance in which it is reasonably foreseeable that such person may purchase or sell such securities with the benefit of such information.

The information presented in this presentation is confidential and expected to be used for the sole purpose of considering the purchase of Magellan services. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential. The attached material shall not be photocopied, reproduced, distributed to or disclosed to others at any time without the prior written consent of the Company.

Confidentiality statement

By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.

The information contained in this presentation is intended for educational purposes only and is not intended to define a standard of care or exclusive course of treatment, nor be a substitute for treatment.

*If the presentation includes legal information (e.g., an explanation of parity or HIPAA), add this: The information contained in this presentation is intended for educational purposes only and should not be considered legal advice. Recipients are encouraged to obtain legal guidance from their own legal advisors.

Confidentiality statement

The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Magellan members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.

*If the presentation includes legal information (e.g., an explanation of parity or HIPAA), add this: The information contained in this presentation is intended for educational purposes only and should not be considered legal advice. Recipients are encouraged to obtain legal guidance from their own legal advisors.