behavioral health provider orientation...treatment, elopement, illegal activity, injuries (including...

Behavioral Health Provider Orientation

SENIOR WHOLE HEALTH OF MASSACHUSETTS

DECEMBER 2020

Agenda

Overview of Magellan

Care coordination

Reimbursement/claims process

Magellan provider website

Commitment to quality improvement

Wrapping up

Magellan provider network

Magellan Healthcare, Inc.Leading Humanity to Healthy Vibrant Lives

• Magellan Healthcare, Inc. (Magellan) is committed to ensuring the delivery of high-quality behavioral healthcare to help individuals and families achieve their goals.

• We partner with local counties, providers, members, families and other stakeholders to ensure a system of care based on innovation, clinical excellence and a philosophy of wellness that focuses on discovering personal strengths, building hope and offering choices.

• Together, we facilitate and accelerate transformation of the behavioral health system, supporting individuals and families on their journey toward recovery, building resilience in their lives and securing a healthier future.

Program information

• Magellan is the behavioral health vendor for Senior Whole Health in Massachusetts.

• Magellan is delegated coverage of all mental health and substance use services that are in-plan benefits. There are no changes in covered benefits as a result of this transition from the previous vendor.

• Magellan covers utilization review, the denial and appeals process, behavioral health network development, and claims processing.

• For resources available to you as a Magellan behavioral health provider, visit www.MagellanProvider.com.

You play an important role in serving Senior Whole Health members.

http://www.magellanprovider.com/

Agenda


Care coordination





Wrapping up

Care coordination

Magellan’s Care Management

program allows for enhanced supports to

be provided by licensed professionals who assist members

with coordination across treating

providers, support during transitions of care, health coaching and ongoing health

assessments.

Magellan is committed to providing person-centered care with a

focus on integrating a member’s behavioral,

physical and social determinants of health. This can be seen within

the development of individualized care

plans, through collaboration within a

member’s support network, and through

connection to community resources.

Through Magellan’s commitment to

integrating care and providing

individualized member support, we can assist members in achieving improved quality of

life, increased independence and

prolonged community tenure.

Care coordination, cont’d

• Magellan’s team of licensed clinicians includes both care coordinators and utilization management care managers.

• Care coordinators work directly with members and provide either short-term assistance or longer-term support. Short-term assistance may be indicated when a member just needs a behavioral health referral and limited follow-up contact afterward. Members may also be engaged for a longer duration and may be indicated for those with enduring health concerns who would benefit from enhanced coordination among a member’s support system.

• Utilization management care managers coordinate with providers on requests for services, either initial requests or continued stay requests.

• Magellan values care coordination and the benefits it has for members in reducing gaps in care and strengthening supports. As such, care coordinators, utilization management care managers, and SWH nurse care managers work collaboratively internally, as well as externally with community supports and providers.

Member access to careOur access-to-care standards enable members to obtain behavioral health services from an in-network provider within a timeframe that reflects the clinical urgency of the situation.

You can obtain higher level of care authorizations 24 hours a day, seven days a week; specialized outpatient service authorizations (such as psych testing) will be covered during business hours.

YOU MUST:Inform members of how to proceed, should

they need services after business hours.

Provide coverage for your practice when

you are not available, including but not

limited to an answering service with

emergency contact information.

Respond to telephone messages in a timely

manner.

Provide immediate emergency services

when necessary to evaluate or stabilize a

potentially life-threatening situation.

Provide services within six hours of a

referral in an emergent situation that is not

life-threatening.

Provide services within 48 hours of a

referral in an urgent clinical situation.

Provide services within 10 business days of

referral for routine clinical services.

Preauthorization process

How to request service authorization

• Phone number: 1-800-770-3084

• Website: www.MagellanProvider.com

- After signing in, select Request Member Care from the left menu.

Medical necessity criteria

• Magellan uses Magellan Care Guidelines.

• Find information on these online at www.MagellanProvider.com (from the Get Information box, select Medical Necessity Criteria).

http://www.MagellanProvider.comhttp://www.magellanprovider.com/

Agenda


Care coordination




Wrapping up



In support of our commitment to quality, providers must be familiar with our guidelines and standards and apply them in clinical work with members.

Key quality measures include:

• Coordination of care

• Grievances

• Notification of adverse incidents

• Monitoring of health needs and referrals for enhanced supports

We obtain feedback through various channels including member and provider satisfaction surveys, our national Provider Services Line, and the Magellan provider website.

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Appeals

Magellan is delegated for all member and provider appeals.

An appeal is used when a member or non-participating provider disagrees with an initial determination or a revised determination related to the stoppage, reduction or restriction on a previously authorized benefit.

• Timeframe within which Magellan will decide about an appeal:

− Expedited: 72 hours

− Standard: 30 calendar days

• Appeal submission options:

− Submit written request, outline the reason for the appeal, and include necessary documentation within 60 calendar days.

− U.S. Mail: Attn: Appeals Department, Magellan Healthcare, 105 Terry Drive, Suite 103, Newtown, PA 18940

− Fax: 1-888-656-6607

− Phone: 1-800-770-3084

Claim appeals/disputes

• A claim appeal/dispute can be filed for a denied claim.

• Submit within 90 business days of the denial letter date or EOB.

• Written request; outline the reason for the appeal and necessary documentation; submit via:

− U.S. Mail: Attn: Appeals Department, Magellan Healthcare, 105 Terry Drive, Suite 103, Newtown, PA 18940

− Fax: 1-888-656-6607

• Magellan will decide about the appeal within 30 calendar days of receipt of the request and provide notification verbally and in writing.

Grievances

A grievance is an expression of dissatisfaction with any aspect of the operations, activities, or behavior of a Medicare health plan, or its providers, regardless of whether remedial action is requested.*

• Senior Whole Health will lead investigations of grievances.

• Submit member and provider grievances to Senior Whole Health in writing or verbally.

• Submit via:

− U.S. Mail: Senior Whole Health, Attn: Member Services, 58 Charles Street, Cambridge, MA 02141

− Fax: 1-617-494-5554

− Phone: 1-888-794-7268 (TTY 711)

*Other than an adverse organization determination, aka denial

Retrospective reviews

A retrospective review is an evaluation for medical necessity and authorization of treatment services after the treatment has been rendered without preauthorization. Magellan can consider retrospective review requests for situations such as being unable to identify member eligibility in an emergency, a member becoming retroactively eligible, or if another, primary insurer was believed to be covering the services in question.

To request a retrospective review, complete Magellan’s Retrospective Review Request Form available at www.MagellanProvider.com and send the form with supporting records to Magellan at:

• Fax (preferred): 1-888-656-6607 or

• Mail to: Attention Retrospective Review, Magellan Healthcare, 105 Terry Drive, Suite 103, Newtown, PA 18940

You must use the Retrospective Review Request Form; Magellan will not process requests received via other methods.

http://www.magellan.com/

Reportable incidents

• Should Magellan receive verbal notification of any reportable incident during care management, Magellan will request the provider complete requisite reporting and send the report to Senior Whole Health.

• Magellan will forward all written reports of Adverse Incidents to Senior Whole Health.

• Senior Whole Health will conduct all research regarding the Adverse Incident.

• Magellan may reach out to providers in cases where additional information is needed about reportable events.

Serious Reportable Adverse Events

(Medicare Part C/CMS); categories of SREs include:

• Surgical or invasive procedure events

• Product or device events

• Patient protection events

• Care management events

• Environmental events

• Radiologic events

• Potential criminal events

To maintain compliance with reporting requirements, you must report the following circumstances to Magellan and Senior Whole Health: Serious Reportable Events (SREs), Sentinel Events, and Other Reportable Events.

Reportable incidents (cont’d)

Sentinel Events

• Disaster management: Preventable patient death or serious injury in a healthcare setting associated with a man-made or natural disaster related to poor disaster management planning and execution.

• Accident: Patient death or serious injury associated with an accident in a healthcare setting. (Note: May include overdose if not intended.)

• Staff misconduct: Patient death or serious injury associated with staff misconduct in a healthcare setting.

• Standard of care: Patient death or serious injury associated with failure to follow facility policy or recognized standard of care protocols not otherwise categorized in a healthcare setting.

• Natural death expected: Patient death or serious injury associated with expected natural causes/ disease process in a healthcare setting.

• Natural death unexpected: Patient death or serious injury associated with unexpected natural causes/ disease process in a healthcare setting.

Reportable incidents (cont’d)

Other Reportable Events

• Access and service-related issues: Appointment scheduling and access, office wait times, office responsiveness.

• Attitude and service-related issues: Lack of caring/concern, poor communication skills, provider/staff rude or inappropriate attitude.

• Clinical practice-related issues: Adequacy of assessment or referral, accuracy of diagnosis, delay in treatment, medication error, failure to follow practice guidelines, over- or under-utilization, prescribing issue.

• Provider unprofessional behavior: Aggressive behavior, inappropriate boundaries/relationship with member, not qualified to perform services.

• Other monitored events: Attempted suicide, adverse reaction to treatment, elopement, illegal activity, injuries (including falls), sexual behavior, self-inflicted harm, other concern representing actual or potential harm to a member.

Agenda


Care coordination





Wrapping up

How to join the Magellan network

• Magellan has been actively reaching out to all providers who have been serving Senior Whole Health members.

• We intend to have all providers on full Magellan agreements prior to the program effective date. We are aggressively working to complete the credentialing and contracting process so you will be a Magellan participating provider in time for the program start date of Jan. 1, 2021.

• We appreciate your willingness to work with us quickly.

How to join the Magellan network (cont’d)

To help expedite the process, please make sure you do the following:

• Organizations: Complete the credentialing application and include all required supporting documents.

• Practitioners in groups or solo practices: Make sure your CAQH data is current.

• All providers: Complete, sign, and return all the contracting and credentialing documents as soon as possible (via email is preferred).

Magellan contracting team:

Phone: 1-800-770-3084Email: [email protected]

mailto:[email protected]

Credentialing/recredentialing

OUR POLICY

Magellan providers are required to successfully complete the credentialing review process prior to being accepted as a network provider and every three years unless otherwise required by applicable state and federal law, a customer and/or an accrediting entity.

Only credentialed providers may render services to Magellan members as in-network providers.

Clinicians affiliated with a group practice must complete the individual credentialing process in order to render covered services to Magellan members.

Credentialing/recredentialing

OUR POLICY, cont’d

Organizations/facilities must successfully complete the credentialing review process prior to being accepted as a network provider and are recredentialed every three years thereafter.

Each service site within a facility requires separate credentialing.

Recredentialing procedures

Ensure that you complete and return your application in a timely manner; not meeting recredentialing timeframes is the most common reason for involuntary termination from the network

Upon receipt of your completed application, we re-verify your credentials, and our Regional Network and Credentialing Committee (RNCC) reviews for continued network participation

We review quality indicators – such as complaints, adverse incidents, and treatment records reviews – during the recredentialing process

Recredentialing for organizationsRecredentialing procedures (cont’d)

1. To monitor network quality, Magellan reviews organization/facility credentials every three years as required by contract and/or applicable state law.

2. Six months prior to the credentialing anniversary, we mail a recredentialing notification to the mailing address on record for the organization/facility.

3. Magellan will make three outreach attempts to acquire any missing data, e.g., updated malpractice information. If the provider does not respond, the recredentialing application will be closed and the provider will be placed in suspended status with a future termination date. Final notification will be issued to the mailing address on file for the organization.

26

Recredentialing for individual practitionersRecredentialing procedures (cont’d)

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

2. Approximately six months prior to the recredentialing due date, Magellan will attempt to access your CAQH application. If we cannot, we will send a notification to mailing address on record. To avoid delays to the recredentialing process, please do the following:

• Log on to CAQH at http://proview.caqh.org and complete your application, sending all required documents to CAQH. Ensure that you have re-attested to your information and have authorized Magellan to access your application.

• If you do not have access to the CAQH universal application, you may request a paper recredentialing application.

3. Magellan will make three outreach attempts to acquire any missing data such as updated malpractice information. If the provider does not respond, the recredentialing application is closed and the provider is placed in suspended status and will be terminated as of the recredentialing due date. Final notification is issued to the mailing address on file for the practitioner.

http://proview.caqh.org/

Magellan contract

ORGANIZATION CONTRACTS

1. To be an in-network provider, the organization/facility must be contracted with Magellan and, in order to be referral-eligible, each contracted location must be credentialed by Magellan.

2. A new location added to the contract, at anytime thereafter, must also be credentialed before being considered an “in-network” location for Magellan.

Magellan contract

GROUP CONTRACTS

1. 1. To be an in-network group provider, the group must be contracted with Magellan and in order to be referral-eligible, the practitioners within the group must be individually credentialed by Magellan.

2. 2. A group member who leaves the group practice and is not also contracted with Magellan under an individual provider participation agreement is no longer considered a Magellan participating provider.

3. 3. Magellan expects all practitioners in a participating group to be credentialed and participating in the Magellan network; members accessing a participating practice must be assured access to participating practitioners.

Magellan contract

GROUP CONTRACTS (continued)

4. When group membership changes (e.g., a practitioner joins or leaves your group):

• You must update your group roster via the Magellan provider website. Note: adding a provider to the group roster does not automatically affiliate them to the group contract or initiate a credentialing application.

• If the new group member is not already Magellan-credentialed, have him/her begin the credentialing process; this must be completed before the provider is eligible to receive referrals.

• Make sure all necessary documentation is completed in order to affiliate a practitioner to your practice, including a Group Association Form and current malpractice information.

Agenda


Care coordination


The Magellan provider website


Wrapping up

The Magellan provider network

Magellan-paid claims requirements

Timely filing of claims:

60 Days

Accepted methods for submission of claims:

• Electronic Data Interface (EDI) via direct submit www.edi.magellanprovider.com

• EDI via a clearinghouse, “Claims Courier” — Magellan’s web-based claims submission tool

• Paper claims on CMS-1500 or UB-04

Address for paper claims:

Senior Whole Health of MAP.O. Box 1808

Maryland Heights, MO 63043

Magellan’s EDI Payer ID#: 01260

http://www.edi.magellanprovider.com

Checking claims status

32

1. Sign into www.MagellanProvider.com

2. Select Check Claims Status from the menu.

3. Search for claim by member or subscriber name, date of service, etc.• View claim details such as check number, date and

payment method.• If claim is denied, reason code and description is

provided.• View EOB online.• Contact Magellan at 1-800-424-6628 with claims-

related questions.

Electronic funds transfer (EFT)

It is mandatory that providers sign up for EFT for Magellan-paid claims

What are the benefits of EFT?• Claims payments get to your

bank account more quickly than the standard process of mailing and cashing or depositing a check

• No risk of lost or misplaced checks

• More time to devote to your practice

Explanation of Benefits (EOB) are available on www.MagellanProvider.com• Sign into the secure network• Click on Check Claims Status from

the left-hand menu• Click on the EOB Search on the top

tab

$

http://www.magellanprovider.com/

Agenda


Care coordination




Wrapping up


MagellanProvider.com

A secure location for your

transactions –sign in and get

started!

You should receive a

username and temporary

password during the contracting

process.

Magellan website features

• Magellan provider handbook

• Handbook supplement for Senior Whole Health

• Medical necessity criteria

• Clinical guidelines

• Credentialing criteria

• Authorizations

• Claims submission and status

• Provider profile application (to enhance the information members see about you in directories)

• Sample PCP communication forms

• Provider data change form

• Group and facility roster maintenance

• Award-winning Magellan provider newsletter, Provider Focus

www.MagellanProvider.com

Agenda


Care coordination


The Magellan provider website


Wrapping up


Key contact information

Effective date: Jan. 1, 2021

For clinical questions, including those about authorization, assessment and treatment planning, or for questions about Magellan website functions, contracting/credentialing and claims, contact:

• Phone number: 1-800-770-3084

• Email: [email protected]

mailto:[email protected]

Thank You!

Questions?

The information contained in this presentation is intended for educational purposes only and is not intended to define a standard of care or exclusive course of treatment, nor be a substitute for treatment.

The information contained in this presentation is intended for educational purposes only and should not be considered legal advice. Recipients are encouraged to obtain legal guidance from their own legal advisors.

behavioral health provider orientation...treatment, elopement, illegal activity, injuries (including...

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