WellFirst Health works with Magellan Healthcare for review and authorization of our Musculoskeletal (MSK) Care Management Program. This includes prior authorization by the treating physician for non-emergent inpatient and outpatient musculoskeletal surgeries, specifically hip, knee, shoulder and lumbar and cervical spine.
This new program incorporates the following key components:
- All WellFirst Health product lines will use the Musculoskeletal (MSK) Care Management Program.
- Magellan’s Musculoskeletal (MSK) Care Management Program manages the medical necessity review for non-emergent inpatient and outpatient musculoskeletal surgeries through physician authorization, prior to performing the surgery.
- Members who require the services of a provider who is not a WellFirst Health Network provider may require two authorizations. The initial authorization will need to be obtained for the use of the non-network provider via the WellFirst Health Utilization Management Department.
- Authorization may be submitted using Magellan’s website RadMD.com or the Magellan toll-free phone number at 866-232-3955 for procedures scheduled on or after Jan. 1, 2020.
- Musculoskeletal surgeries included in this program are non-emergent hip, knee, shoulder, lumbar and cervical spine surgeries. A list of current spine surgery and knee, hip and shoulder surgery CPT codes can be found in the Additional MSK resources section.
Effective for date of service July 1, 2021 and after, only inpatient total knee arthroplasty and total hip arthroplasty will require prior authorization.
Knee
- Effective for date of service July 1, 2021 and after, if a total knee arthroplasty (CPT Code 27447) is done in an outpatient hospital or ambulatory surgery setting, a prior authorization is NOT required.
- All other outpatient hospital or ambulatory setting knee procedures require a prior authorization.
- If the total knee arthroplasty (CPT Code 27447) is done as an inpatient, a prior authorization is required.
Hip
- Effective for date of service July 1, 2021 and after, if a Total Hip Arthroplasty (CPT Code 27130) is done in an outpatient hospital or ambulatory surgery setting, a prior authorization is NOT required.
- All other Outpatient Hospital or Ambulatory Setting hip procedures require a prior authorization.
- If the total knee arthroplasty (CPT Code 27130) is done as an inpatient, a prior authorization is required.
Magellan customer service
You can contact Magellan's customer service representatives Monday through Friday from 7 am to 7 pm (CST) at 866-232-3955.
Additional MSK resources
