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Magellan Health Services PA HealthChoices Provider Training- 2012 PowerPoint PPT Presentation


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Magellan Health Services PA HealthChoices Provider Training- 2012. Magellan Behavioral Health of Pennsylvania- HealthChoices. Welcome to Magellan Behavioral Health of Pennsylvania!

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Magellan health services pa healthchoices provider training 2012

Magellan Health Services

PA HealthChoices

Provider Training- 2012


Magellan behavioral health of pennsylvania healthchoices

MagellanBehavioral Health of Pennsylvania- HealthChoices

Welcome to Magellan Behavioral Health of Pennsylvania!

Contracted providers should be familiar with both the National Provider Handbook and the Magellan HealthChoices Provider Handbook Supplement. For complete information, please view the handbooks at www.MagellanofPA.com (For Providers; Provider Manual). The information included in this presentation is a summary of the policies and procedures presented in the Magellan HealthChoices Provider Handbook Supplement.


Pennsylvania healthchoices

Pennsylvania HealthChoices

What is it?

The HealthChoices Program is the name of one of Pennsylvania's mandatory managed care programs for Medical Assistance recipients.

Through Behavioral Health Managed Care Organizations, recipients receive quality medical care and timely access to appropriate mental health and/or drug and alcohol services. This component is overseen by the Department of Public Welfare's Office of Mental Health and Substance Abuse Services.

Magellan Behavioral Health is subcontracted as the mandatory behavioral health managed care organization in the following HealthChoices counties: Bucks, Delaware, Lehigh, Montgomery and Northampton.


Medical assistance enrollment procedures

Medical Assistance Enrollment Procedures

  • To be eligible to enroll, providers must be licensed and currently registered by the appropriate State agency.

  • To enroll, you must complete a provider enrollment application and any applicable addenda documents, dependent on the provider type, prior to serving HealthChoices members.

  • Base Medicaid Applications are available at the following website address: http://www.dpw.state.pa.us/provider/promise/enrollmentinformation/index.htm

  • Supplemental Medicaid services must be approved by the Behavioral Health MCO (Magellan) and the appropriate county behavioral health office.

  • For assistance with provider types and which type of application you should submit, please contact your Magellan network coordinator.


Medical assistance enrollment continued

Medical Assistance Enrollment (continued)

  • If you move locations, you must complete a new application prior to starting services for the HealthChoices population.  

  • If you are adding a new service to an existing location, you must complete a new application.

  • To terminate association (fee assignment) with a provider group by an individual, you must complete a service location change request form. 

  • To add or terminate participation with a Provider Eligibility Program (PEP), you must complete a service location change request form.

  • See the state's Web site for instructions for the PROMISe™ Provider Service Location Change Request. (Note: this is for a location change, not for adding a new service location.) You must complete a new Provider Enrollment Application or New Service Location Application as applicable, to add a new service location where recipient services are provided.

  • Please be sure to follow these procedures to avoid any interruption in reimbursement from Magellan. As always, you may contact your local Magellan network coordinator with questions or for more information.


Contracting and credentialing

Contracting and Credentialing

To be eligible for referrals and reimbursement for covered services rendered to HealthChoices members, each provider must sign a Magellan Provider Participation Agreement agreeing to comply with Magellan’s policies, procedures, and guidelines.

Providers are contracted as Individual Practitioners, Groups or Organizations.

Individual Practitioners: To be a network provider, individual providers must be both credentialed and contracted by Magellan. Individuals must also be Pennsylvania Medicaid enrolled.

Group Providers: Magellan contracts directly with the Group entity. The group must be contracted with Magellan AND the practitioners within the group must be individually credentialed by Magellan in order to be referral eligible. Both the Group and Individual Practitioners must also be Pennsylvania Medicaid enrolled. Individuals within the Group must be enrolled at each location that they provide services.

Organizations: To be a network provider, organizations must hold an active license through OMHSAS and be credentialed by Magellan. Organizations must also be Pennsylvania Medicaid enrolled.


Credentialing

Credentialing

Credentialing is the process we use to review and verify; and periodically re-review and re-verify a provider’s professional credentials in conjunction with Magellan’s credentialing criteria.

Magellan credentials providers in accordance with NCQA requirements.

The credentialing process includes: Primary Source Verification (PSV) and Regional Network Credentialing Committee (RNCC) review.

If your credentials pass PSV, your application is sent to a regional RNCC meeting consisting of Magellan clinical staff and professional peers. The local RNCC reviews completed credentialing applications and makes the determination for network inclusion.

Magellan will process all credentialing applications within 180 days or in accordance with applicable state or client company guidelines.


Re credentialing

Re-Credentialing

To monitor network quality, Magellan reviews provider credentials every 3 years or as required by contract and/or applicable state law.

Re-credentialing notification is mailed 6 months prior to the credentialing anniversary.

Providers must assure that the application is completed and returned timely as non-compliance with re-credentialing time frames is the most common reason for involuntary termination from the network.

Upon receipt of the application, your credentials are re-verified and are reviewed by the local RNCC for continued network participation.

Quality indicators such as complaints, adverse incidents, and treatment records reviews are reviewed during the re-credentialing process.


Group providers

Group Providers

Group members who leave the group practice and are not also contracted under an individual provider participation agreement with Magellan are no longer considered a Magellan participating provider.

When group membership changes (a practitioner joins or leaves your group):

New group members must complete the credentialing process before they are eligible for referrals.

Complete a group association form in order to affiliate a practitioner with your group. This may be completed on Magellan’s website.


Magellan healthchoices website

Magellan HealthChoices website

  • Magellan Behavioral Health of Pennsylvania was pleased to launch a new website specific to HealthChoices accounts in Bucks, Delaware, Lehigh, Montgomery and Northampton counties in 2010: www.MagellanofPA.com

  • Here, you can find all the resources you need to provide care through the Pennsylvania HealthChoices Program, such as your Pennsylvania Provider Handbook Supplement, and Magellan's National Provider Handbook. You will also find everything you need to stay current about Magellan of Pennsylvania, including the latest updates, practice guidelines and training links, as well as county-specific information.

  • From MagellanofPA.com, you can follow the designated links allowing you to check member eligibility and submit claims electronically (these tools are located on www.MagellanProvider.com).


Www magellanprovider com

www.MagellanProvider.com

Features:

Web Site User Guides

Magellan Provider Handbook and Supplements

Provider Focus Newsletter

Eligibility

Authorization Inquiry

Clinical Practice Guidelines

Medical Necessity Criteria

Claims Inquiry

Electronic Claim Submission Orientation

Claims Courier

EDI Testing Center

Credentialing Status

Group Roster

Edit Practice Information/ Submit W-9

CEU Trainings

Outcomes

PA Outcomes Measurement (POMs)

Forms (Appendices)


Eligibility

Eligibility

Authorization for service is based on eligibility at the time of the treatment request and does not guarantee payment.

Providers are responsible for verifying a member’s eligibility for HealthChoices coverage through the PA Medical Assistance (MA) PROMISe Eligibility Verification System. It’s recommended that providers confirm eligibility:

Prior to the first appointment,

Throughout the course of treatment, and

Prior to submitting claims

For information regarding the different options for checking EVS, go to the below DPW website address: https://promise.dpw.state.pa.us/Provider/provider_access/lessons/03EVS/03EVS.htm or call # 1-800-766-5387 for interactive (real-time) eligibility verification (24/7).

You may also check eligibility on www.MagellanProvider.com (please be advised that this is not real-time eligibility) or by calling Magellan’s customer service department.

When applicable, hard copies of the EVS printout are to be maintained in the member's medical record.


Poms performance outcome measurements system

POMS(Performance Outcome Measurements System)

What is POMS?

POMS is an outcomes tool which the Department of Public Welfare (DPW) established to continuously evaluate the effectiveness of the HealthChoices program. POMS allows DPW to identify members with a serious illness or risk of illness; establishes a data baseline for member function at registration or entry into the HealthChoices system; updates member data as the course of treatment evolves; and finalizes member data at closure of treatment.

Why do we need to complete POMS?

HealthChoices providers are mandated by DPW to collect priority population data and submit POMS data on every HealthChoices member receiving mental health services at certain points during treatment. This is required for Magellan HealthChoices members in Mental Health Treatment Only (not for drug & alcohol treatment).


Poms continued

POMS (continued)

Full POMS data is required for HealthChoices Members if you are:

Treating the member for the first time

Treating for the first time as a Magellan HealthChoices member (the member may have seen you as a MA fee-for-service patient and subsequently converted to HealthChoices)

Treating for the last time (either termination from your care if the member is moving to another provider, or closure if the member is ending all mental health treatment)

Whenever there is a change in any POMS element

POMS can be completed online at www.MagellanProvider.com or faxed to Magellan at 877-769-9779 (using a Treatment Authorization Request form- see next slide).

In order to submit POMS on Magellan’s website, users must have access to ‘PA Measurement Outcomes’. The entity’s website administrator is responsible for granting access.


Treatment authorization request tar forms

Treatment Authorization Request (TAR) Forms

To request approval for outpatient services that require authorization (listed on the appropriate TAR cover sheet), providers should submit the appropriate Treatment Authorization Request form.

The TARs can be located within the Appendices on Magellan’s provider website: https://www.magellanprovider.com/MHS/MGL/about/handbooks/supplements/pa_healthchoices/index.asp

The TAR form will ask providers to verify that they have submitted POMs data on www.MagellanProvider.com.


Care management teams

Care Management Teams

Initial Referral Team

  • Responds to all initial emergent and urgent requests for service (both adults and children)

  • Magellan’s care management information system contains documentation on member treatment history

  • Facilitate appropriate service linkages (based on member’s age and diagnosis) and provision of necessary supports


Care management teams continued

Care Management Teams (continued)

Adult Mental Health (MH) Inpatient Team

  • Completes individual clinical case reviews for acute care and 24-hour levels of service

  • Care managers are assigned specific facilities, giving them the ability to build collaborative relationships with providers for coaching, shaping, and monitoring

  • Review utilization of intensive levels of care to ensure safety, psychiatric stabilization, recovery/resiliency/cultural competency, and optimal return to the community


Care management teams continued1

Care Management Teams (continued)

Regional Drug and Alcohol (D&A) Care Management Team

  • Provides active care management for 24-hour levels of D&A care/ acute partial care

  • Facility assignments and job responsibilities mirror those of the inpatient team


Care management teams continued2

Care Management Teams (continued)

Community Support Care Management Team for Adults

  • Intensive care management for high-risk adults

  • Population-based management of the County community providers, with focus on Assertive Community Treatment (ACT), Community Treatment Team (CTT), Targeted Case Management (TCM), Intensive Psychiatric Rehabilitation (IPR), Intensive Outpatient (IOP), and routine outpatient

  • Organize and facilitate individualized recovery treatment planning conferences

  • HealthChoices HealthConnections case management – integrated PH/BH care strategies

  • Certified Peer Specialist


Care management teams continued3

Care Management Teams (continued)

Children’s Mental Health Inpatient/RTF Team

  • The facilities assigned to the Children’s team specialize in treatment of children and adolescents

  • Team members have specific expertise working with child and adolescent members, their families and providers


Care management teams continued4

Care Management Teams (continued)

Community Support Care Management Team for Children

  • Intensive care management for children

  • Programmatic management of community-based programs that serve youth, including Behavioral Health Rehabilitation Services (BHRS), Multisystemic Therapy (MST), Functional Family Therapy (FFT) and Targeted Case Management (TCM), and routine outpatient

  • Children’s Quality Collaborative (CQC) Care Managers - use a program review approach to ensure that BHRS services are being appropriately utilized and that authorized services are being provided


Authorizations

Authorizations

Routine Outpatient Services are unmanaged by PA HealthChoices (including individual therapy, group therapy, family therapy, psychiatric evaluations, medication checks/medication management). Accordingly, in most cases, contracted providers do not need to receive prior authorization from Magellan for these services (please refer to your contract for specific information).

Psychological Testing: Authorization is required. To avoid potential issues with reimbursement, psychological testing is not to be initiated until an authorization has been received. Preauthorization forms can be faxed to 866-667-7744 (Bucks, Montgomery and Delaware) or 610-814-8049 (Lehigh and Northampton). Preauthorization forms can be found on www.MagellanProvider.com (Appendix Q) or by following this link: https://www.magellanprovider.com/MHS/MGL/about/handbooks/supplements/pa_healthchoices/mainapps/appQ.pdf

90808 U1 or AH (Lehigh/Northampton Only). To receive an authorization for this service providers can call 866-780-3368.


Authorizations continued

Authorizations (continued)

Authorization Report: You can find this report on the Magellan website: www.magellanhealth.com/provider under “Check Authorizations”. You can search for authorizations in a variety of ways: member name, member ID, date of service, date range, etc. You can only view services that require an authorization.

Authorization Letters: This letter will be sent to your facility within several business days (only for those services that require an authorization). You can also view authorization letters on the Magellan website under “Check Authorizations.” You also have the option to discontinue receiving paper authorization letters. We strongly encourage providers to suppress paper authorization letters.


Authorizations continued1

Authorizations (continued)

Family-based services

Multi-Systemic therapy

Behavioral health rehabilitation services for children and adolescents (BHRSCA)

Functional Family Therapy

Family-focused, solution-based services

Mental Health Partial Hospitalization

Acute Inpatient Hospitalization

Residential facilities, including residential treatment facility (RTF), halfway house, drug and alcohol long-and short-term rehabilitation facilities

Detoxification

  • Besides Psychological Testing, preauthorization of services is also required for the following levels of care:

  • Preauthorization of substance abuse partial hospitalization, Community Treatment Team, Mobile Assessment and Stabilization Team, and Program for Assertive Community Treatment is required for Lehigh and Northampton county members.


Concurrent review

Concurrent Review

Services that require Authorization:

If additional treatment is required beyond the initial authorization period, you must contact Magellan in order to obtain approval.

The continued need for a level of care is based on medical necessity and is reviewed on a regular basis. Some reviews are based on paper documentation while other reviews are done telephonically.

The Pennsylvania Department of Welfare (PA DPW) publishes and maintains the following Behavioral Health Medical Necessity Criteria for the HealthChoices Project (located on PA DPW’s website): http://www.dpw.state.pa.us/omap/rfp/hlthchcrfp/HlthChBHAppdxT.asp

For levels of care not included in the DPW criteria (for example, crisis residential, ACT, MST), we have created supplemental MNC.  A link to these criteria can be found at www.MagellanofPA.com.

For adult consumers with drug and alcohol problems, we utilize the Pennsylvania Client Placement Criteria for Adults (PCPC).  For children and adolescents with substance abuse issues, we utilize American Society of Addiction Medicine (ASAM) criteria.


Concurrent review continued

Concurrent Review (continued)

For concurrent review of 24-hour levels of care and acute partial hospital care, the review shall be conducted telephonically with the identified Magellan care manager on the last authorized day.

Please refer to Appendix B (Bucks, Delaware and Montgomery counties) or Appendix LN2 (Lehigh and Northampton counties) to determine if a concurrent review is to be conducted telephonically or on paper.

Please call the appropriate toll-free number to obtain authorization for services:

Bucks and Montgomery Counties Provider Services Line – 1-877-769-9779

Delaware County Provider Services Line – 1-800-686-1356

Lehigh and Northampton Counties Provider Services Line – 1-866-780-3368.


Discharge summary

Discharge Summary

A completed Discharge Summary (Appendix F) is required within 30 days after a member completes a mental health outpatient treatment episode. Please be sure to complete the POMS portion of the Discharge Summary.

For 24-hour levels of care, the care manager reviews the discharge plan telephonically with you on the day of discharge.


Ambulatory follow up

Ambulatory Follow-Up

Ambulatory follow up for members being discharged from an inpatient level of care is a priority to Magellan and our customers as it directly impacts successful treatment outcomes.

While a member is in an inpatient facility, Magellan’s clinical team works with the facility’s treatment team to make arrangements for continued care with outpatient care providers.

Magellan policy requires that members being discharged from an inpatient stay have a follow-up appointment scheduled prior to discharge and that the appointment occurs within 5 days of discharge.


Retrospective reviews

Retrospective Reviews

A Retrospective Review is an evaluation of the medical necessity of treatment services after the treatment has been rendered without preauthorization. Retrospective reviews may be requested under the following circumstances:

Emergency services (Magellan must receive a request for retrospective review within 120 days of the date services were provided).

HealthChoices eligibility is retroactively initiated (Magellan must receive the retrospective review request within 120 days after the service was performed, or within 120 days after the member’s eligibility was established or reasonably discovered).

Service was not covered by the member’s primary insurer (Magellan must receive the retrospective review request within 120 days after the service was performed, or within 120 days of the primary insurer’s final decision notice).

Magellan will not consider network providers’ retrospective review requests that are not submitted within the above timeframes. Magellan will consider, on a case-by-case basis, non-network providers’ retrospective review requests that are not submitted within the above timeframes, since these providers may not be familiar with the above requirements.


Retrospective reviews continued

Retrospective Reviews (continued)

To request a retrospective review, please submit the following to Magellan:

1. A cover letter explaining why treatment was rendered without preauthorization.

2. Sufficient clinical information to establish medical necessity for the services provided.

3. For retrospective review requests due to a member’s retroactive enrollment in HealthChoices, provide evidence that HealthChoices eligibility was checked via Eligibility Verification System (EVS).

4. For requests for retrospective review based on the service not being covered by the member’s primary insurer, include a copy of the Explanation of Benefit (EOB) form or final decision letter.

Submit your request for retrospective review to:

Magellan Behavioral HealthMagellan Behavioral Health

105 Terry Drive, Suite 1031 West Broad Street Suite 210

Newtown, PA 18940Bethlehem, PA 18108

Attn: Retrospective ReviewAttn: Retrospective Review

(Bucks, Delaware, Montgomery Co.)(Lehigh, Northampton Co.)


Claims requirements

Claims Requirements

All claims for covered services provided to HealthChoices Members must be submitted to and received by Magellan as follows:

Within sixty (60) days from date of service for most levels of care except as provided below;

Within sixty (60) days from date of discharge for 24/hr level of care;

Within sixty (60) days of the last day of the month or the discharge date, whichever is earlier when billing monthly for longer treatment episodes of care at a 24/hr level facility;

Within sixty (60) days of the claim settlement for third party claims. This date is based on the date of the other carriers decision.

If Magellan does not receive a claim within these timeframes, the claim will be denied.


Claims submission

Claims Submission

Accepted Methods for Submission of Claims:

Paper Claims: CMS-1500 (Non-Facility-Based Providers) or UB-04 (Facility-Based Providers)

Electronic Data Interface (EDI) via a Third Party Clearinghouse

“Claims Courier”—Magellan’s Web-based Claims submission tool (www.MagellanProvider.com)

Electronic Data Interface via Direct Submit


Claims addresses

Claims Addresses

Paper Claims must be submitted to the below addresses (claims are not accepted at the Care Management Centers):

MBH-Bucks, PO Box 1715, Maryland Heights, MO 63043

MBH-Delaware, PO Box 2037, Maryland Heights, MO 63043

MBH-Lehigh, PO Box 2127, Maryland Heights, MO 63043

MBH-Montgomery, PO Box 2277, Maryland Heights, MO 63043

MBH-Northampton, PO Box 2065, Maryland Heights, MO 63043


Magellan preferred clearinghouses

Magellan Preferred Clearinghouses

Payerpath9030 Stony Point PkwySuite 440Richmond, VA 23235877-623-5706Web site: www.payerpath.com

Capario (formerly MedAvant and ProxyMed) 1901 E Alton Ave, Suite 100Santa Ana, CA 92705800-586-6938 E-mail: [email protected]

Availity (formerly THIN)PO Box 550857Jacksonville, FL 32255-0857800-282-4548Web site: www.availity.com

Emdeon Business Services (formerly WebMD)One Century Place26 Century Blvd, Suite 601Nashville TN 37214877-469-3263 Web site: http://transact.emdeon.com

Gateway EDI, Inc.

One Financial Plaza

501 North Broadway 3rd Floor

St. Louis, MO. 63102

800-969-3666

Web site: www.gatewayedi.com

Relay Health

700 Locust StreetSuite 500Dubuque, IA 520011-800-527-8133, Option 2Web site: www.relayhealth.com

Office AllyPO Box 872020Vancouver, WA 986871-866-575-4120Web site: www.officeally.com


Claims courier

Claims Courier

No-cost web-based data entry application

Professional claims only (no institutional claims)

For credentialed and participating providers

Access www.MagellanProvider.com; Sign-in and go to “Submit a Claim Online.”

For low volume claim submitters who don’t want to use a clearinghouse. 

Similar to the CMS 1500 claim form, with additional fields to make the application HIPAA-compliant

A Claims Courier Demo can be accessed at: www.MagellanProvider.com


Edi direct submission

EDI Direct Submission

Provider sends HIPAA transaction files directly to and receives responses from Magellan without a clearinghouse.

If you are able to create an 837 in a HIPAA compliant format, we recommend EDI Direct Submission.

There is a simple testing process to determine if Direct Submit is right for you.

Direct Submit supports HIPAA 837P and 837I claims submission files.

Freeto providers.

EDI Testing Center

Self-enroll by creating a unique user ID and password

Download EDI guidelines

Upload and test files

Obtain immediate feedback regarding the results of the test.

Independently validate EDI test files to ensure compliance with HIPAA rules and codes.


Edi testing center process direct submission

EDI Testing Center Process (Direct Submission)

Web-based testing is easy to follow

Simple six-step process

You will be assigned an IT analyst to guide you through the process and address any questions

The process typically takes about 3 to 4 weeks to complete the process, so allow ample time to complete your independent testing.

Go to www.edi.MagellanProvider.com to start the process.


Additional information edi

Additional Information- EDI

When using the services of a Clearinghouse, it is critical that the proper Payer ID is used so the EDI claims are sent to Magellan. The following Payer IDs are required for all Clearinghouses, with the exception of Emdeon:

837P Professional: 01260

837I Institutional: 01260

The following unique Payer IDs are for Emdeon only:

837P Professional: 01260

837I Institutional: 12X27

Contact Magellan’s EDI Hotline for support and/or assistance: 1-800-450-7281 ext. 75890 or [email protected]


Resubmission of claims

Resubmission of Claims

Claims with Provider billing errors are called “Resubmissions”.

Resubmissions must be submitted within 60 days from the date of denial.

Resubmitted claims can be sent electronically via a 837 file. There is a specific indicator for an adjusted claim (please consult Magellan’s companion guide or the EDI hotline for assistance).

Resubmitted claims sent via paper should be stamped “Resubmission” and include:

Date of Original Submission

Claim number if applicable


Third party liability tpl

Third Party Liability (TPL)

Medicaid is always the last payer; therefore providers must exhaust all other insurance benefits first, before pursuing payment through Magellan HealthChoices.

Claims for services provided to HealthChoices Members who have another primary insurance carrier must be submitted to the primary insurer first in order to obtain an EOB. HealthChoices will not make payments if the full obligations of the primary insurer are not met.

As a Magellan provider, you are required to hold HealthChoices members harmless and cannot bill them for the difference between your contracted rate with Magellan and your standard rate. This practice is called balance billing and is not permitted.


Resubmission of claims mbh website

Resubmission of Claims- MBH Website

  • Corrections can be made to claims submitted on Magellan’s website on the same day prior to 3 p.m. CST. Click View Claims Submitted Online and “Edit” by the appropriate claim.

  • For claims corrections on a different day than submitted or after 3 p.m. CST, the following fields can be amended: Place of Service, Billed Amount; or Number of Units. This functionality is only available for claims with a status of Received/ Accepted.

  • Corrections to claims other than Place of Service, Billed Amount or Units can be submitted on hard copy corrected claim via postal mail. Note “corrected claim” on the form.


Claims processing

Claims Processing

  • In accordance with applicable law, Magellan will pay clean claims within 45 days of the date of receipt. Clean claims are defined as claims that can be processed without obtaining any additional information from the provider or from a third party (Magellan pays 90% of all claims within 30 days of receipt).

  • Upon receipt of a claim, Magellan reviews the documentation and makes a payment determination. As a result of this determination, a remittance advice, known as an Explanation of Payment (EOP) is sent to you. The EOP includes details of payment or the denial. It is important that you review all EOPs promptly.

  • Check Runs are weekly pending the county of eligibility:

    - Bucks= Thursday- Lehigh= Friday

    - Delaware= Wednesday- Northampton= Friday

    - Montgomery= Friday


Common billing errors

Common Billing Errors

The following are common claims errors that may result in a denial. Double check all claims prior to submission to avoid delays due to these errors:

Authorized units do not match billed units

More than one month of service is billed on one claim form

Recipient’s ID is missing (Please use Medicaid ID numbers)

Recipient’s date of birth is missing

Itemized charges are not provided when a date span is used for billing

EOB is not attached to third-party claim form

Revenue code, procedure code and/or modifier(s) are incorrect

Duplicate claim submissions are not identified as “resubmissions” or “corrected claims”.

Diagnosis code is not an accepted code (current ICD-9 codes are required).

Service and/or diagnosis billed is not permitted under the provider’s license.


Claims appeals

Claims Appeals

Claims that Providers feel were denied incorrectly are labeled as “Appeals”.

If you receive a claim denial, you have sixty (60) days from the date of receipt to file a written appeal. Your appeal must include supporting documentation that refutes the reason for the denial. Upon receipt of your written appeal, Magellan will investigate the information presented and respond within 30 days.

Options for submitting Appeals are as follows:

Providers should submit a cover letter explaining the denied claim appeal and attach supporting documentation.

If submitting more than 10 appeals please put appeal information on a spreadsheet. Information needed:

Claim number

Member Name

MA Recipient Number/Social Security Number

Date of service

Procedure code/Modifier(s)

Denial Code/Reason(s)


Commitment to quality improvement

Commitment to Quality Improvement

Magellan has collaborated with the Counties and providers to develop a Quality Improvement Program that strives to improve the delivery of services to HealthChoices members. Magellan has implemented processes and procedures to gather information that is used to improve the quality of care. When we collect and evaluate information specific to you we will communicate the findings to you, the findings will be communicated to you.

Our Quality Improvement Program includes: Evaluation of Quality of Care, primarily through Site Visits and Chart Audits; Utilization and Outcomes Studies; Review of Administrative Policies and Procedures; and Technical Assistance and Consultation support.


Adverse incidents

Adverse Incidents

Providers are required to notify Magellan within 24 hours of the occurrence of a reportable incident involving a HealthChoices member. Please see Appendix Y in the Provider Handbook for the definition and instructions for reporting adverse incidents.

Adverse Incident Forms are also available on www.MagellanProvider.com. (Handbook Supplement and Appendices; see Appendix X).


Advanced directives

Advanced Directives

  • Mental Health Advance Directives are a way an individual can plan for their future mental health care in case they can no longer make mental health care decisions on their own as a result of illness. Individuals can do this by creating a Mental Health Declaration or by appointing a Mental Health Power of Attorney or both.

    • A Mental Health Declaration is a set of written instructions that will tell a provider the following: what kind of treatment an individual prefers; where an individual would like to have their treatment take place; and specific instructions an individual has about their mental health care treatment.

    • A Mental Health Power of Attorney is a document that allows an individual to name a person, in writing, to make mental health care decisions for them if they are unable to make them on their own.

  • An advocacy organization such as the Mental Health Association in Pennsylvania at 1-866-578-3659 or 717-346-0549; email: [email protected] can provide assistance.

  • It is important that individuals share their written Mental Health Advance Directives with mental health care providers so that they may be followed.


Prescribing practitioner data collection form

Prescribing Practitioner Data Collection Form

Magellan is required by the Office of Mental Health and Substance Abuse Services (OMHSAS) to collect information on providers in our network who prescribe medications. This information is compiled and reported on a quarterly basis to OMHSAS, and the information is shared with the HealthChoices Physical Health HMOs.

Providers must supply this information to Magellan on a quarterly basis, so that we can provide the most accurate information to OMHSAS and the HMOs. Your reports are due to Magellan by the first day of the month following the close of each quarter (January 1, April 1, July 1, October 1). If the first of the month falls on a weekend or holiday, the report is due the next business day.


Reporting changes in practice status

Reporting Changes in Practice Status

Providers should notify Magellan in writing or through the provider Web site within ten (10) days of any changes, additions or deletions related to their practice information.

Service, Mailing or Financial Address; Telephone number; Business Hours; E-mail Address; Taxpayer Identification or NPI number

Inability to accept referrals for any reason

Additions or Deletions to a Group

Your responsibility is to notify us if any of the following credentialing information changes:

Licensure;

Certification(s);

Hospital Privileges;

Insurance Coverage

Past or pending malpractice actions.


Provider complaints

Provider Complaints

A provider complaint is defined as any oral or written communication made by a provider to a Magellan employee expressing dissatisfaction with any aspect of Magellan operations, activities, or staff behavior. If the concern is on behalf of a specific member, it will be classified as a “member complaint” and the member complaint policy will be followed (please see provider handbook for complete information).

To register a complaint, call the Provider Services Line at 1-877-769-9779 for Bucks, Delaware and Montgomery counties providers, and 1-866-780-3368 for Lehigh and Northampton counties providers. Ask to speak with a customer service representative, or you may submit your complaint in writing to:

MagellanMagellan

105 Terry Dr. Suite 1031 West Broad Street, Suite 210

Newtown, PA 18940 Bethlehem, PA 18108

Attn: ComplaintsAttn: Complaints

(Bucks, Delaware, Montgomery)(Lehigh, Northampton)


Grievances

Grievances

  • A grievance is defined as a request by a member, a member’s representative, or provider with written consent of the member to have Magellan reconsider a decision concerning the medical necessity and appropriateness of a health care service. A grievance may be filed regarding a Magellan decision to:

    • deny or issue a limited authorization of a requested service, including the type or level of service;

    • reduce, suspend, or terminate a previously authorized service;

    • deny the requested service but approve an alternative service.

  • To register a grievance, call the Provider Services Line at 1-877-769-9779 for Bucks, Delaware and Montgomery counties providers, and 1-866-780-3368 for Lehigh and Northampton counties providers. Ask to speak with a customer service representative, or you may submit your grievance in writing to:

    MagellanMagellan

    105 Terry Dr. Suite 1031 West Broad Street, Suite 210

    Newtown, PA 18940 Bethlehem, PA 18018

    Attn: GrievancesAttn: Grievances

    (Bucks, Delaware, Montgomery)(Lehigh, Northampton)


  • Member complaints

    Member Complaints

    • A member complaint is defined as any oral or written communication made by a member, or the member’s representative with the member’s written consent, to a Magellan employee expressing dissatisfaction with a participating provider’s operations, activities, or staff behavior, orany aspect of Magellan operations, activities, or staff behavior.

    • To assist a member in registering a complaint, call the Provider Services Line at 1-877-769-9779 for Bucks, Delaware and Montgomery counties providers, and 1-866-780-3368 for Lehigh and Northampton counties providers. Ask to speak with a customer service representative, or you may help a member submit a complaint in writing to:

      MagellanMagellan

      105 Terry Dr. Suite 1031 West Broad Street, Suite 210

      Newtown, PA 18940 Bethlehem, PA 18018

      Attn: ComplaintsAttn: Complaints

      (Bucks, Delaware, Montgomery)(Lehigh, Northampton)


    Physical health managed care organizations

    Physical Health Managed Care Organizations

    HealthChoices members in Bucks, Delaware, Lehigh, Montgomery and Northampton Counties have a choice of enrolling with a Physical Health plan for their medical needs.

    Each HealthChoices HMO maintains a “special needs” division to coordinate and case manage medical and behavioral care.

    HealthChoices recipients will each have an Access card which indicates their Physical Health HMO on the front of their card and their Behavioral Health HMO (Magellan) on the back.


    Physical health managed care organizations1

    Physical Health Managed Care Organizations

    PA HEALTHCHOICES MANAGED CARE PHYSICAL HEALTH CARE

    PLAN CONTACT INFO:

    • Bucks, Delaware & Montgomery Counties:

      • AmeriChoice – 800-321-4462 ; www.americhoice.com

      • Health Partners – 800-553-0784 ; www.healthpart.com

      • Keystone Mercy Health Plan – 800-521-6860 ; www.kmhp.com

      • Aetna Better Health – 866-638-1232 ; www.aetnabetterhealth.com

      • Coventry Cares – 866-903-0748 ; www.healthamerica.coventryhealthcare.com

    • Lehigh & Northampton Counties:

      • Unison/ MedPlus – 800-414-9025 ; www.unisonhealthplan.com

      • AmeriHealth – 888-991-7200 ; www.amerihealthmercyhp.com

      • Gateway – 800-392-1147 ; www.gatewayhealthplan.com

      • Aetna Better Health – 866-638-1232; www.aetnabetterhealth.com

      • UPMC – 866-353-4345 ; www.upmchealthplan.com


    Transportation

    Transportation

    Emergency transportation services are the responsibility of the member’s HMO. When a member is in need of emergency ambulance transportation and Magellan is notified of the emergent need, we will follow procedures set forth by the member’s HMO to arrange for the service.

    Requests for non-emergency transportation can be made to the following agencies.

    Lower Bucks: 215-741-0866 (Bucks County)

    Central Bucks: 215-343-4140 (Bucks County)

    Upper Bucks: 215-249-9626 (Bucks County)

    Community Transit: 610-490-3977 (Delaware County)

    MA Transportation: 610-432-3200 (Lehigh & Northampton County)

    Transnet: 215-542-7433 (Montgomery County)


    Compliance

    Compliance

    • Magellan conducts Compliance Audits

      • Verify that providers adhere to Fraud, Waste, & Abuse policies

      • Encourage providers to conduct periodic self audits to ensure quality services in accordance with laws, regulations & policies

        • Quality Clinical Audits

        • Internal Claims Audits


    Fraud waste abuse

    Fraud, Waste & Abuse

    • Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or herself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

    • Waste means over-utilization of services or other practices that result in unnecessary costs

    • Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices and result in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to federally an/or state-funded health care programs, and other payers.


    Examples of fraud waste and abuse

    Billing for services or procedures that have not been performed

    Submitting false information about services performed or charges for services performed

    Duplicate billing

    Misrepresenting the services performed (aka up-coding)

    Violation of another law (Anti-Kickback Statute, etc.)

    Submitting claims for services ordered by a provider that has been excluded from participating in federally and/or state-funded health care programs

    Lying about credentials such as degree & licensure info

    Providing or ordering medically unnecessary services

    Providing services by an unlicensed or unqualified individual

    Examples of Fraud, Waste and Abuse


    Compliance program guidance

    Compliance Program Guidance

    • CMS (Centers for Medicare and Medicaid Services) developed guidelines in 2005 to assist providers in developing and implementing effective compliance programs that promote adherence to, and allow for, the efficient monitoring of compliance with all applicable statutory, regulatory and Medicare program requirements”

    • Compliance programs should both articulate & demonstrate the provider’s commitment to ethical and legal conduct. Includes all aspects of an organization, from the board of directors or CEO to each individual.

    • CMS’s Compliance guidelines can be found at the following link: http://www.cms.gov/MedicareContractingReform/Downloads/compliance.pdf


    7 requirements for an effective compliance program

    7 requirements for an effective compliance program

    • Written Policies & Procedures

    • Designation of a Compliance Officer & Compliance Committee

    • Conducting effective training and education

    • Developing effective lines of communication

    • Auditing and monitoring

    • Enforcement through publicized disciplinary guidelines and policies dealing with ineligible persons

    • Responding to detected offenses, developing corrective action initiatives and reporting to government authorities


    Pennsylvania medical assistance provider self audit protocol

    Pennsylvania Medical Assistance Provider Self-Audit Protocol

    • MA Bulletin # 99-02-13

    • Provides general background info on the Bureau of Program Integrity (BPI) and remind providers of the administrative sanctions available to BPI to ensure compliance with applicable regulations.

    • Provides info on the Provider Self-Audit Protocol

    • Applies to all providers enrolled in the Medical Assistance Program


    Reporting fraud waste or abuse anyone can report suspected fraud waste or abuse

    Reporting Fraud, Waste or Abuse: Anyone can report suspected fraud, waste, or abuse

    • Magellan Special Investigations Unit 1-800-755-0850 or [email protected]

    • Magellan Corporate Compliance 1-800-915-2108 or [email protected]

    • PA Medical Assistance Provider Compliance Hotline 1-866-DPW-TIPS or online at: http://www.dpw.state.pa.us/PartnersProviders/MedicalAssistance/DoingBusiness/FraudAbuse/003673490.aspx


    Member services lines

    Member Services Lines

    Members may Contact Magellan at:

    Bucks County Member Services Line

    1-877-769-9784

    1-877-769-9785 TDD

    Delaware County Member Services Line

    1-888-207-2911

    1-888-207-2910 TDD

    Lehigh County Member Services Line

    1-866-238-2311

    1-866-238-2313 TDD

    Montgomery County Member Services Line

    1-877-769-9782

    1-877-769-9783 TDD

    Northampton County Member Services Line

    1-866-238-2312

    1-866-780-3367 TDD


    Healthchoices network contact list

    HealthChoices Network Contact List

    Toll-Free Provider Lines:

    800-686-1356 (Delaware County)

    877-769-9779 (Bucks & Montgomery Counties)

    866-780-3368 (Lehigh & Northampton Counties)

    Fax numbers:

    866-667-7744 (Bucks, Montgomery and Delaware Counties)

    610-814-8066 (Lehigh & Northampton Counties)

    Contacts:

    Scott Donald- Network Director

    Mitch Fash- Senior Field Network Coordinator

    Rich Kupniewski- Contract Manager

    Patricia Marth- Field Network Coordinator

    Karli Strohl- Senior Field Network Coordinator


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