Appeals Overview

Paula Brooks Appeals Administrator Magellan Health in Louisiana

What is an Appeal?

A request for review of an adverse decision (provider advised a service is denied)

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Types of Appeals

Standard • Can be requested after an adverse decision has been rendered • Requires member’s written consent • Must be submitted to Magellan within 30 days of the adverse decision • 30 day timeframe for resolution

Expedited • Can be requested while the member is still admitted for urgent care services and

the provider feels the adverse decision would seriously jeopardize the life or health of the member

• Can be requested by the provider on the member’s behalf • 72 hour timeframe for resolution

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What happens when an Appeal is Received?

1. It is Magellan’s responsibility to send a written acknowledgement of receipt. (This applies to standard appeals only)

2. The appeal is reviewed by physicians who were not previously involved in the decision.

3. It is our responsibility to send a notice of resolution letter once the physician has made a final decision within 30 days of receipt of the appeal. (Expedited appeals will also receive a verbal notification and will occur within 72 hours of the request)

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What is a Retrospective Review?

A review of medical necessity for services rendered in the past

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When will a retro review request be denied?

1. If the facility failed to obtain a pre-certification for a member with active coverage.

2. If the facility failed to follow up for concurrent review

3. If claims for services were submitted prior to the request for retrospective review.

When can a request for retro review be submitted?

1. The member received retroactive eligibility from Medicaid.

2. Upon admission, the member was in a gravely disabled state and unable to provide insurance coverage information

**Requests for retrospective reviews must be submitted within 365 days after the date of service**

Retro Review Requests

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What is a Claims Dispute?

Provider initiated disputes regarding one of the following: 1. Disagrees with payment of a claim 2. Disagrees with denial of a claim 3. Disagrees with recoupment of

payment for a claim

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Helpful Tips Regarding Claims Disputes

1. Claim disputes must be submitted within 180 calendar days of the date of the Explanation of Payment (EOP).

2. If the claim has been submitted and denied for no authorization, a retrospective review request cannot be submitted.

3. If the claim has received a clinical denial and the provider did not submit an appeal of the clinical denial within 30 days of receiving the adverse decision, the claim will remain denied.

4. Clinical information will not be reviewed for Claims Disputes.

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Grievances and Complaints

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Dawn Foster Quality Improvement Magellan Health in Louisiana

Grievances/Complaints

Magellan provides a formalized process for both members and providers to express dissatisfaction concerning any matter – with the exception of denials or reduction/termination of services which are handled through the Appeals process.

Examples of Grievances and Complaints Examples of possible Member Grievance: “He (the provider) was very rude to me. “

“ The receptionist was unprofessional and was loudly telling everyone in the waiting room my business!”

“ The member services person gave me the wrong information.”

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Examples of possible Provider Complaints: “ The Care Manager told me the service was authorized, but

now my claim is denied.” “We contacted the other provider to try to coordinate

services, but they ignored our request and stole our clients.” “We faxed our authorization request three weeks ago and still

haven’t gotten an answer.”

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Examples of Grievances and Complaints (Cont.)

How to File Grievances and Complaints

Members can file grievances and Providers file complaints: By phone: Any Magellan staff member can take the member’s or provider’s

expression of dissatisfaction over the phone. In writing: Members or Providers can express their dissatisfaction in writing

and mail it to: Magellan Health Services Attn: Grievance P.O. Box 84380 Baton Rouge, LA 70884 Additionally Members may file a grievance Online: Members may log

onto Magellan of Louisiana and submit an online grievance through our Magellan Health Services secure messaging system for members.

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Next Steps: Entry and Acknowledgement

Immediately upon receipt all Grievances and Complaints are entered into an internal tracking system called CART (Comment And Resolution Tracking).

The Grievance/Complaint Coordinator checks for new entries multiple times daily.

All Grievances and Complaints are immediately acknowledged by an Acknowledgement letter via the USPS

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Final Steps: Investigation and Resolution

The Grievance/Complaint Coordinator investigates the issue with the resolution contractually required within 30 days.

A Resolution letter summarizing the response to the grievance/complaint is mailed to the complainant.

A stricter time line of 14 days is followed in the case of Quality of Care issues involving Members covered under the 1915(i) State Plan Amendment or (c) Waiver.

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Appeals, Grievances and Complaints – Magellan’s role following the integration

• We are currently working closely with DHH in developing a detailed transition plan for the LBHP

• This plan includes the Appeals, Grievances and Complaints which relate to services on or before November 30th; however, may not be reported or resolved until after the transition

• It will explain the process and timelines as we move beyond the integration into Bayou Health

Details will come as we move closer to the transition!

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QUESTIONS?

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Confidentiality Statement for Educational Presentations

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By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc. 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.

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