Medical Injectables Program Update: Claims Review Process for Certain Medical Injectables

Horizon Blue Cross Blue Shield of New Jersey collaborates with Magellan Rx Management a specialty pharmaceutical management company, to conduct medical necessity and appropriateness reviews (MNARs) for specific injectable medications through our Medical Injectables Program (MIP).

Beginning March 18, 2019, claims for services rendered on and after March 18, 2019 will be processed as noted below.

CLAIM PROCESSING ENHANCEMENTS

The processing of claims for services rendered on and after March 18, 2019 will be based on the approved dosage and frequency, in addition to the approved dates and units, authorized in the MNAR.¹

• Those services included on claims where the submitted information is consistent with the information within the approved MNAR will be processed and reimbursed appropriately.
• Those services included on claims where the submitted information does NOT match the information within the approved MNAR will be denied. Appeal rights will be included with all such denials.

Physicians, other health care professionals, hospitals and ancillary providers are reminded to contact Magellan Rx Management if there are any frequency/dosage changes resulting from a patient’s changed medical condition so that these may be included as part of the final MNAR.

MRxM CLAIM REVIEW

Though not subject to MNAR as part of the MIP, the medical injectable drug codes below included on claims for services rendered on and after March 18, 2019, will be reviewed to ensure the billing details are appropriate per our medical policy guidelines.¹

Reimbursement Policies to be Implemented

Claims for services rendered on and after March 18, 2019 will be processed according to the guidelines of the following new Horizon BCBSNJ reimbursement policies.

• Non-ESRD ESA Level Reporting
• Drug Wastage – Modifier JW

We encourage you to click the links above and review the guidelines of these reimbursement policies.

If you have any questions, please contact your Network Specialist, Network Hospital Specialist or Ancillary Contracting Specialist.

¹ We encourage you to review the medical policy criteria and guidelines for the injectable medications included as part of the MIP within our Medical Policy Manual.

OBTAINING A PRE-SERVICE MNAR DETERMINATION

Obtaining a pre-service MNAR determination through Magellan Rx Management helps expedite claims processing.

If you do not obtain a pre-service MNAR determination, your claims may be delayed or denied while information required to establish medical necessity and appropriateness of the services rendered is requested and reviewed.

Submit MIP MNAR requests through Magellan Rx Management’s secure website. If you don’t already have a username and password, we encourage you to request them today.

• Visit ih.magellanrx.com
• Click the Providers and Physicians icon.
• Click New User Request Access (within the yellow Sign In section).
• Click Contact Us.
• Complete the required fields and then click Send.

To initiate a request for pre-service registration of medical injectable drugs to be administered in a patient’s home as part of the Horizon Care@Home program, call CareCentrix at 1-855-243-3321.

Magellan Rx Management is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in conducting medical necessity and appropriateness reviews (MNARs) for specific injectable medications. Magellan Rx Management is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey. This document contains references to brand name prescription medicines that are trademarks or registered marks of pharmaceutical manufacturers that are not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross Blue Shield Association.