Musculoskeletal program

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. See a list of MSK-affected CPT codes.


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