Tennessee Pharmacists Association

In response to calls and questions from members, TPA staff requested and participated in a conference call with representatives from Magellan to discuss the recent letter that was sent to pharmacists and to gain guidance regarding further actions pharmacists need to take to resolve this issue.

Thank you to the TPA members who provided the technical, historical, and anecdotal information that facilitated our discussions with Magellan.

The primary focus of this Magellan claims audit is to determine whether or not the pharmacist verified that the patient had no other primary insurance coverage prior to processing the claim using the Other Coverage Code of 1 (OCC-1).

In September of 2014, Magellan provided a notice that TennCare would no longer allow pharmacies to submit the OCC-1, and the effective date for this change was October 8, 2014. The notice is online at http://bit.ly/magellan-sept2014. (TPA communicated this information to members in an email broadcast on September 9, 2014.)

Prior to October 8, 2014, TennCare allowed pharmacies to use the OCC-1 through a strict process that included a) processing the claims using the other primary coverage information provided by TennCare, as well as b) the receipt of a rejection from that other primary insurance, which provided sufficient documentation of lack of coverage. Magellan initiated the recent claims review, on behalf of TennCare, because several pharmacy software vendor systems were hard-coding the OCC-1 to automatically process claims, and some pharmacies were not going through the verification process required by TennCare.

If a pharmacy received a letter from Magellan, the pharmacist will need to first contact Magellan to request their Excel spreadsheet containing the pharmacy’s list of claims for review. Send this request to Kimberly Baugh, Senior QI Specialist for Quality and Process Improvement at Magellan, at knbaugh@magellanhealth.com

Magellan has provided the following further instructions to assist pharmacists in preparing a response to Magellan regarding the list of claims in question:

CLAIM: If the pharmacist attempted to process the patient’s claim(s) using the other primary insurance information provided by TennCare, and it rejected because no other primary insurance existed, then this is sufficient evidence. The pharmacist will need to type “CLAIM” into the specific field on the spreadsheet. By typing “CLAIM”, the pharmacist is verifying that they used the OCC-1 code properly after verifying that the patient did not have other primary coverage.

  • Per Magellan, it is not required for the pharmacist to send supporting evidence (such as screenshots) with the completed Excel spreadsheet. However, the pharmacist may want to provide such information to Magellan for verification. It is also advised that pharmacists should retain evidence of this verification in case of future audits.
  • The claims list provided by Magellan may include patients with multiple claims. In cases where a pharmacist is able to document verification that no other coverage existed for a patient, the pharmacist may be able to use that information to also verify the patient’s remaining claims listed on the spreadsheet. However, the pharmacist will still need to type “CLAIM” into each field for that patient in the spreadsheet.
  • Per Magellan, using only a patient’s word that no other coverage exists is not sufficient, and TennCare requires further verification. In the case that a pharmacist discovers that other primary coverage exists, pharmacists are instructed to try to rebill the patient’s primary insurance, which is provided on the spreadsheet. The primary rejection message received from Magellan will instruct the pharmacist on how to proceed and rebill the claim.
  • If the pharmacist receives a “Claim Too Old” message from the patient’s other primary insurer after reviewing the claim, which indicates that the timely filing window is closed, pharmacists are instructed to call the patient’s primary insurer and provide a detailed explanation of this issue and to request that the insurer rebill the claim using the date of service for the claim. Magellan believes that the insurer may reopen the window for processing Medicaid claims in order to comply with the Deficit Reduction Act, which is the reason for this claims audit. If the insurer reopens the window to reprocess the claim(s), the pharmacist is instructed to proceed with reprocessing. However, if the insurer does not reopen the window, then the pharmacist is instructed to document this on the spreadsheet and contact Magellan for further instructions.
  • If the pharmacist determines that the primary insurance identified by Magellan is actually a prescription discount card and not true insurance, the pharmacist should type “CLAIM” or “DISCOUNT CARD” in the designated space and further clarify that the patient’s primary insurance reported on the spreadsheet is actually a discount card.

NO CLAIM: If the pharmacist never attempted to process the claim through the patient’s other primary insurance provided by TennCare, or if the pharmacist has tried all of the steps above but cannot verify that the patient did not have other primary coverage at the time of the claim, the pharmacist is then instructed to type “NO CLAIM” into the necessary field. If the pharmacist types “NO CLAIM” into the field, then the pharmacist is stating that they have no evidence and they did not attempt to verify that the patient did not have other primary coverage prior to using the OCC-1 Code. In this instance, Magellan has indicated that they will recoup the money from these selected claims.

SUBMISSION OF COMPLETED SPREADSHEET: The pharmacist must then submit the completed report back to Magellan, to the attention of Kimberly Baugh atknbaugh@magellanhealth.com.

QUESTIONS AND FURTHER GUIDANCE: If you have questions or need further guidance from Magellan during this process, contact Kimberly Baugh by email atknbaugh@magellanhealth.com or by phone at 804-548-0573.