How to Work with Us

We appreciate your commitment to serving our special needs population. We value our network providers and realize your time is best spent with members – not with excessive administrative tasks. To ensure we provide the best care possible, we’ve assembled provider guidelines here.

How do we participate in Magellan’s provider network?

To participate in our plan, providers must be directly contracted and credentialed with MCC of VA (HMO SNP) or be part of a larger entity contracted with us. For detailed instructions, please visit Join Our Network.

For answers to all your provider questions, please phone our Provider Network at 1-800-424-4495 or email us at MCCVAProvider@MagellanHealth.com.

How do we find and use the Provider Portal?

Follow this link to our secure MCC of VA (HMO SNP) Provider Portal. This tool simplifies your tasks and gives you more time for patient care. After you’ve registered, you can log in to:

  • Check members’ eligibility and medical services
  • Identify needed providers
  • Check the status of submitted claims
How do we refer patients to MCC of VA (HMO SNP)?

For enrollment: You may refer patients who have Medicare and Medicaid (dual-eligibles) or refer patients who have only Medicaid and are eligible for Medicare. They should call us at 1-800-424-4497 (TTY 711). We are happy to help your patients enroll in MCC of VA (HMO SNP). Our staff can link callers to interpreters speaking more than 30 different languages.

For assistance: The Member Services team is trained to answer questions regarding membership and enrollment, benefits and services, providers and pharmacies, coverage determinations, appeals and grievances, claims, emergent health situations and more.

Please have them phone Member Services at 1-800-424-4495 Monday through Friday from 8 a.m. to 8 p.m. (from October 1-March 31, 7 days a week). Members can leave voice messages during non-business hours.

Be sure to tell them we have free interpreter services when they call us. As a provider, you are required to identify the need for interpreter services for and offer assistance to your patients who are MCC of VA (HMO SNP) members.

What is a Care Coordination Team and what is my role on it?

The Magellan Model of Care is distinctive for its personalized, inclusive, team-based model of care. It is designed to treat the whole person, with a focus on individualized, culturally-sensitive medical and non-medical support.

Patient care begins with each member’s participation in their own Care Coordination Team, which includes their Nurse Care Manager (NCM), primary care provider (PCP), family member or caregiver as desired, and a plan Community Resource Coordinator (CRC). They’re also supported by plan pharmacists, behavioral health specialists and other providers. As a provider, you play a critical role in working on the team regarding patients’ diagnoses, treatments, services and resources.

What is an Individualized Care Plan (ICP)?

The Care Coordination Team works with the patient to create a health plan for every member. Each ICP is based on:

  • Member PCP and Care Coordinator assessments, along with other assessments and service recommendations
  • The member’s functional, physical, behavioral and psychosocial needs
  • The member’s self-management goals and objectives (to the extent possible)
  • Health promotion and preventive services
What is the Utilization Management team?

Our Utilization Management (UM) team performs many functions including but not limited to concurrent reviews, prior authorizations, discharge planning assistance and retrospective reviews. Our Utilization Management program goal is to optimize the use of healthcare resources for our members. Our members’ health is always our number one concern.

For questions, comments, or to obtain our utilization management criteria in writing, please contact us by mail, email or phone.

Magellan Complete Care of Virginia
Attn: Utilization Management Department
3829 Gaskins Road
Glen Allen, VA 23233

Phone: 1-800-424-4495

Email :  MCCVAProvider@MagellanHealth.com

How does prior authorization work?

Requirements:

  • Prior authorization is required for some services through MCC of VA (HMO SNP)’s Utilization Management department, which is available 24 hours a day, 7 days a week.
  • Providers are expected to submit a pre-service authorization request prior to providing the service or care.
  • Payment will be denied for any services requiring authorization if prior authorization was not received.
  • If members receive care from out-of-network providers without prior authorization, MCC of VA (HMO SNP) will not pay for this care. PCPs should contact us if they wish to request an exception referral for the member to see an out-of-network provider.
  • If an out-of-network provider provides emergency care to a member, the service will be paid.

Materials & Forms:

  • Visit Provider Materials to retrieve the most up-to-date lists of drugs and services requiring prior authorization
  • Visit Provider Forms to download any forms you might need
  • Completed forms should be faxed to 1-888-656-2391
  • Please be sure to include all required supporting documentation

Decisions:

  • Decisions on standard prior authorization requests will be rendered within 14 calendar days from the date of receipt of the request.
  • Decisions on expedited prior authorization requests will be rendered within 72 hours from the date we receive the request if we determine that the request qualifies for expedited consideration. We will notify you if the request will not be considered as an expedited request.
  • We base our decisions for approved services on appropriateness of care and service and existence of coverage.

For more information:

How do I ask for a formulary exception?

When you believe a patient needs a different prescription drug than one that appears on our formulary, you can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make for your patient:

  • You can ask us to cover the drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on the drug.
  • You can ask us to provide a higher level of coverage for the drug.

You can request a Part D coverage determination online or in writing; read more here. We’ll answer your request for Part D prescription drugs within 72 hours of receiving your request. If you need a fast decision, we’ll answer within 24 hours.

Can we file an appeal on behalf of our members?

Providers may appeal a decision made by us that terminates, suspends, delays, reduces or denies a service to their patient. To file an appeal on the member’s behalf:

Consent: The provider must have the member’s written consent.

  • Download and complete the CMS Appointment of Representative Form and ask the member to sign it.
  • Submit the AOR form along with the request for reconsideration, providing details of the medical care the patient was denied by:
  • Fax to 1-855-838-7998 and call us to discuss the appeal at 1-800-424-4495.
  • Email the form to MCCVAProvider@MagellanHealth.com
  • Mail to:
    MCC of VA (HMO SNP)
    Attn: Member Services
    58 Charles Street
    Cambridge, MA 02141
  • You must make your appeal request within 60 calendar days from the date of the written notice of denial we sent.

Standard Appeals: Generally, we use the standard deadlines for giving you our decision.

  • For medical items or services: requests will be answered within 30 calendar days of receiving your appeal request if your appeal is for services the member has not yet received.
  • For prescription drugs: requests will be answered within 7 calendar days after we receive your appeal.
  • We will give you our decision sooner if the member’s health condition requires us to.

Expedited (Fast) Appeals: If the situation is urgent, you may request an expedited appeal. To get an expedited appeal, the following criteria must be met:

  • You can get a fast coverage decision only if you are asking for coverage for medical care the member not yet received.
  • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your patient’s health or hurt their ability to function.
  • For medical items and services: requests will be answered within 72 hours of receipt.
  • For prescription drugs: requests for a Medicare Part B prescription drug will be answered within 24 hours.

If your appeal is denied, you will have the right, upon the member’s request, to make additional appeals. See Chapter 9 of the Evidence of Coverage for more details.

Can we file a grievance on behalf of our members?

A provider may also file a grievance on behalf of a dissatisfied member, at the member’s request. A grievance is any member complaint or dispute expressing dissatisfaction with the operations, activities or behavior of a plan sponsor, or a complaint regarding the timeliness, appropriateness of, access to and setting of a provided service, procedure or item. To file a grievance on the member’s behalf:

Consent: The provider must have the member’s written consent.

  • Submit the AOR form along with the request for reconsideration, providing details of the medical care the patient was denied by:
  • Fax to 1-855-838-7998 and call us to discuss the appeal at 1-800-424-4495.
  • Email the form to MCCVAProvider@MagellanHealth.com
  • Mail to:
    MCC of VA (HMO SNP)
    Attn: Member Services
    58 Charles Street
    Cambridge, MA 02141

Standard grievance: For a standard grievance, we will notify the member and/or the member’s designated representative of our findings within 30 days of its filing.

Expedited grievance: If you request an expedited grievance, we will respond to your request within 24 hours.

See Chapter 9 of the Evidence of Coverage for more details.

What is the policy regarding reimbursement for claims?
  • As a participating provider with MCC of VA (HMO SNP), you have established a contractual agreement to provide physical, behavioral and/or other long-term support services to our members. The arrangement is fee-for-service for the provision of covered healthcare services unless otherwise specified under your Participating Agreement.
  • The rates established in your Participating Agreement are considered full payment for covered services provided. Accordingly, MCC of VA (HMO SNP) members may not be billed for any remaining amounts and/or differences between what is billed and your negotiated reimbursement rates defined in the rate exhibit of your Participating Provider Agreement.
  • As a participating MCC of VA (HMO SNP) provider, you agree to bill all covered services provided to MCC of VA (HMO SNP) members on the required forms and/or electronic claims file format. All claims should be billed on a fully completed CMS 1500 or UB04 to be considered for adjudication and/or payment.
  • You may visit the Centers for Medicare and Medicaid Services (CMS) website at www.cms.hhs.gov to obtain more information about these forms and/or for more instruction and/or information on the proper use of claims forms for services.
What is the policy for timely filing of claims?

MCC of VA (HMO SNP) pays clean claims submitted for covered services provided to eligible members. In most cases, we pay clean claims within 30 days. A remittance advice is provided for all claims payments. The remittance advice addresses paid and denied, but not pended, claims. A clean claim must be submitted within 90 days of the date of service or discharge and/or within your specific contract terms. When a member’s care is ongoing, a claim must be submitted within 90 days of the last day of the month. We request that providers bill every 30 days. The final bill must be received within 90 days of the last date of service.

See Section 5 of the MCC of VA (HMO SNP) Provider Handbook for more information on claims, filing and reimbursement.

How do I submit electronic claims to MCC of VA (HMO SNP)?

MCC of VA (HMO SNP) accepts electronic claims through the clearinghouse as its preferred method of claims submission. All files submitted to MCC of AZ (HMO SNP) must be in the ANSI ASC X12N format, version 5010A or its successor version. Claims submitted via EDI must comply with HIPAA transaction requirements. EDI claims are to be sent via clearing house. We work with Change Healthcare and Ability Network.

For claims to be routed to Independence Care Systems, please be sure to include our payer ID number — MCC02. This pin is the identifier at the clearinghouse to route claims directly to the Claims Operations Department.

See Section 5 of the MCC of VA (HMO SNP) Provider Handbook for more information on claims, filing and reimbursement.

How do I submit paper claims to MCC of VA (HMO SNP)?

MCC of VA (HMO SNP) accepts submissions of properly coded claims from providers by Electronic Data Interchange (EDI) or standard paper claims. The provider acknowledges and agrees that each claim submitted for reimbursement reflects the performance of a covered service that is fully and accurately documented in the member’s medical record prior to the initial submission of any claim. No reimbursement or compensation is due should there be a failure in such documentation.

We encourage all providers to submit electronic claims whenever possible. We recognize, however, that some providers may choose to submit for reimbursement using industry-standard paper claim forms. If the provider does submit paper claim forms, both CMS 1500 and UB 04 are acceptable.

See Section 5 of the MCC of VA (HMO SNP) Provider Handbook for more information on claims, filing and reimbursement.