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Pharmacy Provider Manual

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Pharmacy Provider Manual Pharmacy Provider Manual All Rights Reserved This Pharmacy Providers Manual and other documents provided to Participating Pharmacies owned by MC-21, are confidential and remain the property of MC-21 LLC. The information contained in these documents cannot be released to third parties without the written consent of MC-21 LLC. Table of Contents Introduction .......................................................................................................................................... 7 General Information ............................................................................................................................. 7 2.1. About the Pharmacy Providers Manual ................................................................................................ 7 2.2. Contact Us ............................................................................................................................................. 8 Contact Information ............................................................................................................................. 8 3.1. MC-21 Offices ....................................................................................................................................... 8 3.2. Pharmacy Network (Credentialing and Re-Credentialing) .................................................................... 8 3.3. Pharmacy Network Call Center ............................................................................................................. 9 3.4. Prior Authorization (PA) Call Center ..................................................................................................... 9 3.5. Pharmacy Auditing & FW&A Department ............................................................................................ 9 Defined Terms ..................................................................................................................................... 11 MC-21 Pharmacy Network Providers .................................................................................................. 13 5.1. Pharmacy Enrollment and Participation ............................................................................................. 14 5.2. Pharmacy Credentialing Application ................................................................................................... 14 5.3. Credentialing Standards ...................................................................................................................... 15 5.3.1. Licensure ......................................................................................................................................... 15 5.3.2. Insurance ........................................................................................................................................ 15 5.3.3. Drug Enforcement Agency Controlled Substance Registration Certificate ..................................... 16 Pharmacy Inspections ......................................................................................................................... 16 6.1. Contracting Terms .............................................................................................................................. 17 6.2. Pharmacy Network Participation ........................................................................................................ 17 6.2.1. Chain Pharmacies ............................................................................................................................ 17 6.3. Re-Credentialing ................................................................................................................................. 17 Participating Pharmacy Providers Responsibilities ............................................................................. 18 7.1. AdvertisinG and Promotions ............................................................................................................... 18 7.2. License Requirements ......................................................................................................................... 18 7.3. Reporting of Investigations and Disciplinary Actions .......................................................................... 18 7.4. Changes in Pharmacy Profile .............................................................................................................. 19 7.4.1. Update Information with NABP ...................................................................................................... 19 7.4.2. Changes in Documentation and Other Information ....................................................................... 19 7.4.3. Ownership or Control Changes of a Pharmacy Provider ................................................................. 19 7.5. Quality Standards ................................................................................................................................ 19 7.5.1. Quality Assurance ProGrams ........................................................................................................... 19 7.6. Pharmacy Good Practices ................................................................................................................... 20 7.7. Code of Conduct & Ethics ................................................................................................................... 20 7.8. Privileged Health Information ............................................................................................................. 20 7.9. Confidentiality and Proprietary Rights ................................................................................................ 21 7.10. Court Orders, Subpoenas or Governmental Requests ........................................................................ 21 7.11. Non Discrimination ............................................................................................................................. 21 7.12. Pharmacy Hours and Conditions ......................................................................................................... 22 7.13. Failures in the Communication System .............................................................................................. 22 7.14. EliGibility Verification and Identification ............................................................................................. 22 7.15. Claims .................................................................................................................................................. 22 7.16. Medications Not Covered ................................................................................................................... 23 7.17. Deductible, Copayment ...................................................................................................................... 23 7.18. SiGnature ReGistry ............................................................................................................................... 23 7.19. Record Retention ................................................................................................................................ 24 Termination of AGreement ................................................................................................................. 24 8.1. No Cause Termination ........................................................................................................................ 24 8.2. Termination for Breach ....................................................................................................................... 24 8.3. Immediate Suspension or Termination ............................................................................................... 24 8.4. Specific Network Termination ............................................................................................................ 25 8.5. Termination Due to Claims Processing Volume .................................................................................. 25 8.6. Termination Due to Closure of Business ............................................................................................. 26 8.7. Effect of Termination .......................................................................................................................... 26 Payment Guidelines ............................................................................................................................ 26 9.1. Pricing Benchmark: Average Wholesale Price (AWP) ......................................................................... 26 9.2. Maximum Allowable Cost (MAC) List .................................................................................................. 26 9.3. Claims Payment .................................................................................................................................. 26 9.4. Remittance Advice .............................................................................................................................. 27 9.5. Claims Payment Adjustments ............................................................................................................. 27 9.5.1. Unpaid Claims ................................................................................................................................. 27 9.5.2. MAC Price Reimbursement DisaGreements .................................................................................... 27 9.5.3. Disputed Claims .............................................................................................................................
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