Provider - Magellan of Pennsylvania

Report
Magellan Health Services
PA HealthChoices
Provider Training- 2012
Magellan Health Services, Inc.
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Magellan Behavioral 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.
Magellan Health Services, Inc.
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Pennsylvania HealthChoices
What is it?
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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.
Magellan Health Services, Inc.
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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/ind
ex.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.
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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.
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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.
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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.
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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.
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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):
o New group members must complete the credentialing process
before they are eligible for referrals.
o Complete a group association form in order to affiliate a
practitioner with your group. This may be completed on
Magellan’s website.
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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).
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www.MagellanProvider.com
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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)
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Eligibility
o Authorization for service is based on eligibility at the time of the
treatment request and does not guarantee payment.
o 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
o 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).
o 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.
o When applicable, hard copies of the EVS printout are to be maintained in
the member's medical record.
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POMS (Performance Outcome Measurements System)
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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).
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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.
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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/han
dbooks/supplements/pa_healthchoices/index.asp
 The TAR form will ask providers to verify that they have
submitted POMs data on www.MagellanProvider.com.
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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
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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
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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
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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
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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
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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
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Authorizations
o 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).
o 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/p
a_healthchoices/mainapps/appQ.pdf
o 90808 U1 or AH (Lehigh/Northampton Only). To receive an authorization for
this service providers can call 866-780-3368.
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Authorizations (continued)
o 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.
o 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.
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Authorizations (continued)
 Besides Psychological Testing, preauthorization of services is also required for
the following levels of care:
 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 longand short-term rehabilitation facilities
 Detoxification
 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.
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Concurrent Review
Services that require Authorization:
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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.
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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:
o Bucks and Montgomery Counties Provider Services Line – 1-877-769-9779
o Delaware County Provider Services Line – 1-800-686-1356
o Lehigh and Northampton Counties Provider Services Line – 1-866-780-3368.
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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.
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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.
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Retrospective Reviews
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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).
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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.
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Retrospective Reviews (continued)
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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.
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Submit your request for retrospective review to:
Magellan Behavioral Health
105 Terry Drive, Suite 103
Newtown, PA 18940
Attn: Retrospective Review
(Bucks, Delaware, Montgomery Co.)
Magellan Behavioral Health
1 West Broad Street Suite 210
Bethlehem, PA 18108
Attn: Retrospective Review
(Lehigh, Northampton Co.)
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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.
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Claims Submission
Accepted Methods for Submission of Claims:
1. Paper Claims: CMS-1500 (Non-Facility-Based
Providers) or UB-04 (Facility-Based Providers)
2. Electronic Data Interface (EDI) via a Third Party
Clearinghouse
3. “Claims Courier”—Magellan’s Web-based Claims
submission tool (www.MagellanProvider.com)
4. Electronic Data Interface via Direct Submit
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Claims Addresses
 Paper Claims must be submitted to the below addresses (claims
are not accepted at the Care Management Centers):
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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
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Magellan Preferred Clearinghouses
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Payerpath
9030 Stony Point Pkwy
Suite 440
Richmond, VA 23235
877-623-5706
Web site: www.payerpath.com
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Gateway EDI, Inc.
One Financial Plaza
501 North Broadway 3rd Floor
St. Louis, MO. 63102
800-969-3666
Web site: www.gatewayedi.com
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Capario (formerly MedAvant and
ProxyMed)
1901 E Alton Ave, Suite 100
Santa Ana, CA 92705
800-586-6938
E-mail: [email protected]
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Relay Health
700 Locust Street
Suite 500
Dubuque, IA 52001
1-800-527-8133, Option 2
Web site: www.relayhealth.com
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Availity (formerly THIN)
PO Box 550857
Jacksonville, FL 32255-0857
800-282-4548
Web site: www.availity.com
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Office Ally
PO Box 872020
Vancouver, WA 98687
1-866-575-4120
Web site: www.officeally.com
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Emdeon Business Services (formerly
WebMD)
One Century Place
26 Century Blvd, Suite 601
Nashville TN 37214
877-469-3263
Web site: http://transact.emdeon.com
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Claims Courier
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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
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EDI Direct Submission
o Provider sends HIPAA transaction files directly to and receives
responses from Magellan without a clearinghouse.
o If you are able to create an 837 in a HIPAA compliant format, we
recommend EDI Direct Submission.
o There is a simple testing process to determine if Direct Submit is right
for you.
o Direct Submit supports HIPAA 837P and 837I claims submission files.
o Free to providers.
o 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.
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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.
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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: 1-800-4507281 ext. 75890 or [email protected]
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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:
o Date of Original Submission
o Claim number if applicable
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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.
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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.
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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
- Delaware= Wednesday
- Montgomery= Friday
- Lehigh= Friday
- Northampton= Friday
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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”.
o Diagnosis code is not an accepted code (current ICD-9 codes are required).
o Service and/or diagnosis billed is not permitted under the provider’s license.
o
o
o
o
o
o
o
o
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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)
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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.
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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).
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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.
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Prescribing Practitioner Data Collection Form
o 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.
o 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.
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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.
o Service, Mailing or Financial Address; Telephone number; Business Hours; Email Address; Taxpayer Identification or NPI number
o Inability to accept referrals for any reason
o Additions or Deletions to a Group

Your responsibility is to notify us if any of the following credentialing
information changes:
o
o
o
o
o
Licensure;
Certification(s);
Hospital Privileges;
Insurance Coverage
Past or pending malpractice actions.
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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:
Magellan
105 Terry Dr. Suite 103
Newtown, PA 18940
Attn: Complaints
(Bucks, Delaware, Montgomery)
Magellan
1 West Broad Street, Suite 210
Bethlehem, PA 18108
Attn: Complaints
(Lehigh, Northampton)
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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:
o deny or issue a limited authorization of a requested service, including the type or level of
service;
o reduce, suspend, or terminate a previously authorized service;
o 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:
Magellan
105 Terry Dr. Suite 103
Newtown, PA 18940
Attn: Grievances
(Bucks, Delaware, Montgomery)
Magellan
1 West Broad Street, Suite 210
Bethlehem, PA 18018
Attn: Grievances
(Lehigh, Northampton)
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Member Complaints
o 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, or any aspect of Magellan operations,
activities, or staff behavior.
o To assist a member in registering a complaint, call the Provider Services Line at 1877-769-9779 for Bucks, Delaware and Montgomery counties providers, and 1-866780-3368 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:
Magellan
Magellan
105 Terry Dr. Suite 103
Newtown, PA 18940
Attn: Complaints
(Bucks, Delaware, Montgomery)
1 West Broad Street, Suite 210
Bethlehem, PA 18018
Attn: Complaints
(Lehigh, Northampton)
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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.
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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
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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)
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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
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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.
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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
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Compliance Program Guidance
o 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”
o 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.
o CMS’s Compliance guidelines can be found at the following link:
http://www.cms.gov/MedicareContractingReform/Downloads/complian
ce.pdf
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7 requirements for an effective compliance
program
1.
2.
3.
4.
5.
6.
7.
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
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Pennsylvania Medical Assistance Provider SelfAudit 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
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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 1-866DPW-TIPS or online at:
http://www.dpw.state.pa.us/PartnersProviders/MedicalAssist
ance/DoingBusiness/FraudAbuse/003673490.aspx
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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
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HealthChoices Network Contact List
 Toll-Free Provider Lines:
o 800-686-1356 (Delaware County)
o 877-769-9779 (Bucks & Montgomery Counties)
o 866-780-3368 (Lehigh & Northampton Counties)
 Fax numbers:
o 866-667-7744 (Bucks, Montgomery and Delaware Counties)
o 610-814-8066 (Lehigh & Northampton Counties)
 Contacts:
o
o
o
o
o
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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