Musculoskeletal program

Doctor helping patient with shoulder issue

Prevea360 Health Plan 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 program incorporates the following key components:

  • It includes the following Prevea360 Health Plan product lines:
    • Commercial – Prevea360 HMO, Prevea360 POS and Prevea360 PPO
    • Dean Administrative Services Only (ASO) 
    • Prevea360 Advantage
  • 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 Prevea360 Health Plan Network provider may require two authorizations. The initial authorization will need to be obtained for the use of the non-network provider via Prevea360 Health Plan Utilization Management Department.
  • Authorization may be submitted using Magellan’s website www.RadMD.com or the Magellan toll-free phone number at 877-642-0622.
  • 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 Hip 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 877-642-0622.

Additional MSK resources