Magellan Behavioral Health* Provider Handbook Supplement for Florida True Health

Magellan Behavioral Health* Provider Handbook Supplement for Florida True Health Table of Contents Section 1. Section 2. Section 3. Section 4. Introduction Program Description/Covered Benefits 1-1 Covered Benefits/Mandatory Services 1-2 Magellan Provider Network (See the Magellan National Provider Handbook) Reporting Changes in Practice Status 2-1 The Role of the Provider and Magellan Member Access to Care 3-1 Initiating Care 3-2 Concurrent Review 3-4 Advance Directive Medical Records 3-6 3-7 Quality Partnership Commitment to Quality 4-1 Cultural Competency 4-2.xcv.,xc,v.,cx Provider Input 4-3 Member Action Appeal Process 4-4 Provider Complaints and Appeals Process 4-6 Members Rights and Responsibilities 4-8 Section 5. Provider Reimbursement Professional Services 5-1 Section 6. Fraud, Waste and Abuse 6-1 * Magellan Behavioral Health, Inc.; Magellan Behavioral Health Systems, LLC, f/k/a Human Affairs International; CMG Health, Inc.; Green Spring Health Services, Inc.; Merit Behavioral Care; Magellan Health Services of Arizona, Inc.; Magellan Health Services of California, Inc. Employer Services; Human Affairs International of California; Magellan Behavioral Care of Iowa, Inc.: Magellan Behavioral Health of Florida, Inc.; Magellan Behavioral of Michigan, Inc.; Magellan Behavioral Health of New Jersey, LLC; Magellan Behavioral Health of Pennsylvania, Inc.; Magellan Behavioral Health Providers of Texas, Inc.; and their respective affiliates and subsidiaries are affiliates of Magellan Health Services, Inc. (collectively Magellan ). Magellan Behavioral Health of Florida 2013 Magellan Health Services 1/13 Florida True Health Handbook Supplement This document is the proprietary information of Magellan.

1. Introduction Welcome to the Magellan Behavioral Health Provider Handbook Supplement for Florida True Health. This handbook supplements the Magellan National Provider Handbook, addressing policies and procedures specific for Florida True Health. The handbook supplement for Florida True Health is to be used in conjunction with the national handbook. When information in the Florida True Health supplement conflicts with the national handbook, or when specific information does not appear in the national handbook, policies and procedures in the Florida True Health supplement prevail. Program Description Magellan will provide the following services and programs: Claims payment for all services covered under the contract, network services, member services (except verification of eligibility and benefits), inpatient pre-certification and concurrent review, discharge planning and after-care follow-up, intensive case management with co-location, care management, outpatient concurrent review, and after hours care management. Covered Benefits Magellan manages the provision of medically necessary services, pursuant to the Florida State Medicaid Plan and in accordance with the Community Behavioral Health Services Coverage and Limitations Handbook and the Mental Health Targeted Case Management Handbook. Providers should furnish medically necessary services in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to recipients under fee-for-service Medicaid. Magellan will not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of the diagnosis, type of illness or condition. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 1-1

1. Introduction Covered Benefits/Mandatory Services Mandatory Services Description A. Emergency Services Involuntary Emergency Psychiatric Evaluation and Admission B. Inpatient hospital services Inpatient psychiatric services are medically necessary mental health care services provided in a general hospital or specialty hospital setting under the direction of a licensed physician with the appropriate Medicaid specialty requirements. Adults: Non-Reform Counties: Maximum 45 inpatient days per fiscal year Reform Counties: BH and medical inpatient days are combined towards the 45 day limit. Pregnant Females have 365 days of inpatient care. Children (Ages 0 to 21): Non-Reform Counties: 45 inpatient days per fiscal year Reform Counties: Unlimited inpatient days C. Crisis Stabilization Units Crisis stabilization units provide 24-hour medically supervised care. Adults: 2 for 1 towards total inpatient benefit. Two (2) CSU days count as one inpatient day. Adults: Non-Reform Counties: Maximum 90 CSU days per fiscal year [count towards inpatient maximum] Reform Counties: BH and medical inpatient and CSU days are combined towards the 45 day limit. Pregnant Females, have combined 365 days of inpatient care. Children (Ages 0 to 21): Non-Reform Counties: Maximum of 90 CSU days [count towards inpatient maximum] Reform Counties: Unlimited CSU days Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 1-2

1. Introduction Mandatory Services D. Outpatient hospital services 1. emergency room 2. psychiatric clinic 3. psychiatric electroshock treatment 4. psychiatric visit/individual therapy 5. psychiatric/testing Description Outpatient hospital services are medically necessary mental health care services provided in a hospital setting under the direction of a licensed physician that are paid at a line-item rate for covered outpatient revenue center codes. E. Physician services Physician services are those services rendered by a licensed physician who possesses the appropriate Medicaid specialty requirements including specialty consultations and coordination of care with the primary care physician. F. Community mental health services 1. individualized treatment plan development and modification 2. evaluation and assessment services 3. medical and psychiatric services 4. mental health counseling/therapy services 5. psychosocial rehabilitative services 6. therapeutic behavioral onsite services 7. crisis intervention mental health services and post-stabilization care services Community mental health services encompass a continuum of services that are provided for the maximum reduction of the member s disability and restoration to the best possible functional level. Coverage is in accordance with the Community Behavioral Health Services Coverage and Limitations Handbook G. Mental health targeted case management Targeted case management services are provided to children with serious emotional disturbance (SED) and adults with severe and persistent mental illness (SPMI) and incorporate the principles of a strengths-based approach that stresses building on the strengths of individuals to resolve current problems and issues. Coverage is in accordance with the Mental Health Targeted Case Management Handbook H. Intensive case management This service is intended to provide case management to highly recidivistic adults with SPMI to help them remain in the community and avoid institutional care. Coverage is in accordance with the Mental Health Targeted Case Management Handbook For more specific information, please call Magellan at 1-800-327-7921. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 1-3

2. Provider Network Reporting Changes in Practice Status Our Philosophy Our Policy We are diligent about maintaining our provider database with the current practice information submitted by our providers in support of our commitment to members to provide quality care. Providers should notify our credentialing administration department in writing or through the Magellan provider website, immediately of any action to suspend, revoke, or restrict an affiliated provider s license and/or any other accreditation or certification. What You Need to To comply with this policy, your responsibility is to notify us if any of the following credentialing information changes: Licensure Certification Hospital privileges Insurance coverage and/or Past or pending malpractice actions. What Magellan Will Magellan s responsibility is to: Update your record in a timely manner to reflect the new information. Notify you if your change in information impacts your referral status. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 2-1

3. Role of the Provider and Magellan Member Access to Care Our Philosophy Our Policy What You Need to Magellan believes that members are to have timely access to appropriate mental health and substance abuse services from an in-network provider 24 hours a day, seven days a week. We require in-network providers to be accessible within a time frame that reflects the clinical urgency of the member s situation. Your responsibility is to: Provide access to services 24 hours a day, seven days a week. 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 emergent services immediately. Treat requests for psychiatric medication as a request for emergency services when a member is without necessary prescribed medication. Provide for urgent appointments within 23 hours of the request. Provide appointments for routine initial outpatient services within seven days. Contact Magellan immediately if member does not show for an appointment following an inpatient discharge so that Magellan can conduct appropriate follow up. Contact Magellan immediately if you are unable to see the member within the timeframes. Comply with AHCA s Appointment Waiting Times. What Magellan Will Magellan s responsibility to you is to: Communicate the clinical urgency of the member s situation when making referrals. Assist with follow-up service coordination for members transitioning to another level of care. Magellan will process requests for authorization within the following timeframes: For expedited service requests, within one business day of Magellan s receipt of a complete request. For concurrent inpatient service requests, within one business day of Magellan s receipt of a complete request. For routine service requests, within five business days of Magellan s receipt of a complete service request. For retrospective service requests, within 14 calendar days following Magellan s receipt of a complete request. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 3-1

3. Role of the Provider and Magellan Initiating Care Our Philosophy Magellan joins with our members, providers and customers to make sure members receive the most appropriate services and experience the most desirable treatment outcomes for their benefit dollar. Our Policy We assist members in optimizing their benefits by reviewing and authorizing the most appropriate services to meet their behavioral health care needs. Magellan conducts timely prior-authorization reviews in order to evaluate the member s clinical situation and determine the medical necessity of the requested services. We do not pay incentives to employees, peer reviewers (e.g., physician advisors), or providers to reduce or forego the provision of clinically necessary care. We do not reward or offer incentives to encourage denials or under-utilization of behavioral health care services. What You Need to Your responsibility is to: Understand federal and state Medicaid standards applicable to providers. Comply with federal Medicaid standards. Contact Magellan for pre-certification of inpatient services at 1-800-327-7921. Allow members to schedule all routine outpatient appointments without prior authorization with an in-network provider. Not require a primary care physician (PCP) referral from members. Not require pre-certification of members for emergency services, post-stabilization services, urgent care services or second opinions. Contact Magellan for prior authorization of all non-emergent out-of-network services at 1-800-327-7921. What Magellan Will Magellan s responsibility to you is to: Operate a toll-free telephone hotline to respond to provider questions, comments and inquiries. That number is 1-800-327-7921. Establish a multi-disciplinary Utilization Management Oversight Committee to oversee all utilization functions and activities. Provide prior authorization decisions that are non-urgent within the timeframe outlined in Section 3. Provide authorization decisions for acute care services within 24 hours of receipt of complete information. Upload the authorization for viewing on the provider website. Mail an authorization letter only if requested within the timeframe outlined in Section 3. Not require pre-certification of members for emergency services, post- stabilization services, urgent care services or second opinions. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 3-2

Florida True Health Authorization Grid* Service Prior-authorization required Concurrent review required Involuntary Emergency Services No No Voluntary Acute Inpatient Hospital Mental Health No* Yes Crisis Stabilization Unit (CSU) No Yes Inpatient Substance Abuse Rehab Special population only pregnant members Yes Yes Outpatient Hospital Care Emergency Room No N/A Psychiatric Clinic No No* Psychiatric Electroshock Therapy Yes Yes Psychiatric Visit/Individual Therapy No No* Psychological Testing* Yes N/A Physician Services No N/A Outpatient Mental Health Services Targeted and Intensive Case Management Yes Yes Psychosocial Rehabilitative Services Yes Yes Therapeutic Behavioral Onsite Services (TBOS) Yes Yes Individualized Treatment Plan Development and Modification No No Evaluation and Assessment Services No N/A Medical and Psychiatric Services No No Mental Health Counseling/Therapy Services No No* Crisis Intervention and Post Stabilization Care Services No No * These levels of care may be reviewed as a result of the following Utilization Review and/or Quality Improvement review triggers: Under- and over-utilization Adverse incident and quality of care review Chart audit failure Treatment inconsistent with clinical practice guidelines. Fraud, Waste and Abuse Monitoring Retrospective Medical Necessity review Acute Voluntary Inpatient Care requires notification and registration in order to coordinate discharge planning and ensure continuity of care after discharge planning. Providers will be notified in writing of such reviews. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 3-3

3. Role of the Provider and Magellan Concurrent Review Our Philosophy Our Policy What You Need to Magellan believes in supporting the most appropriate services to improve health care outcomes for members. We look to our providers to notify us if additional services beyond those initially authorized are needed, including a second opinion for complex cases. Concurrent utilization management review is required for some services, including but not limited to the following. Please see the grid on the previous page for authorization information on: Targeted Case Management (TCM/ICM) Therapeutic Behavioral Onsite Services (TBOS) Psychosocial Rehabilitation (PSR) Psychological Testing If, after evaluating and treating the member, you determine that additional services are necessary for which a concurrent review is required (see grid on previous page) Contact the designated Magellan care management team member at least one day before the end of the authorization period by telephone at 1-800-327-7921. Request an extension on an authorization date span should you have visits that have not been used and the authorization date span has elapsed. Request a second opinion if you feel it would be clinically beneficial. In-network requests do not require prior approval. Understand federal and state Medicaid standards applicable to providers. Comply with federal and state Medicaid standards. Complete a Request Rehab Authorization online at www.magellanhealth.com/provider to request continued authorization for the non-routine outpatient services that require authorization (refer to Florida True Health Authorization grid on previous page). Contact Magellan for pre-certification of inpatient services at 1-800-327-7921. Provide available and accessible services to covered members 24 hours a day, seven days per week in a manner that assures continuity of care. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 3-4

3. Role of the Provider and Magellan Concurrent Review What Magellan Will Magellan s responsibility to you is to: Promptly conduct clinical review of your request for additional acute care days and provide an authorization decision within the timeframe outlined in Section 3. Respond within the timeframe outlined in Section 3, to your request for additional sessions/units for those services that require authorization and concurrent review (see authorization grid). Call you directly if additional clinical information is needed. Offer you the opportunity and contact information to discuss the determination with a Magellan peer reviewer if we are unable to authorize the requested services based on clinical criteria. Conduct retrospective audits of selected cases for quality of care purposes. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 3-5

3. Role of the Provider and Magellan Advance Directive Our Philosophy Our Policy What You Need to What Magellan Will Magellan believes in a member s right to self-determination in making health care decisions. As appropriate, Magellan will inform adult members 18 years of age or older about their rights to refuse, withhold or withdraw medical and/or mental health treatment through advance directives. Magellan supports the state and federal regulations, which provide for adherence to a member s psychiatric advance directive. Your responsibility is to: Understand federal and state Medicaid standards regarding psychiatric advance directives. Meet federal and state Medicaid standards regarding psychiatric advance directives. Maintain a copy of the psychiatric advance directive in the member s file, if applicable. Understand and follow a member s declaration of preferences or instructions regarding behavioral health treatment. Use professional judgment to provide care believed to be in the best interest of the member. Magellan s responsibility to you is to: Meet state of Florida and federal advance directive laws. cument the execution of a member s psychiatric advance directive. Not discriminate against a member based on whether the member has executed an advance directive. Provide information to the member s family or surrogate if the member is incapacitated and unable to articulate whether or not an advance directive has been executed. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 3-6

3. Role of the Provider and Magellan Medical Records Our Philosophy Our Policy What You Need to What Magellan Will In support of our commitment to quality care, we request that our providers maintain organized, well-documented member treatment records that reflect continuity of care for members. We expect that all aspects of treatment will be documented in a timely manner, including face-to-face encounters, telephone and electronic contacts, clinical findings and interventions. For quality improvement purposes, Magellan generally reviews treatment records with providers receiving a high volume of referrals from Magellan, as required by our customers or as part of a quality review. Your responsibility is to: Maintain organized, well-documented member treatment records consistent with professional practice standards and state/federal requirements. Meet state requirements for completion and submission of FARS/CFARS testing. Promote coordination of care with members primary medical providers and/or other behavioral health providers as appropriate. Follow the detailed instructions provided if you are selected for an onsite or desktop review. Submit for review, at provider expense, legible copies of requested records. Cooperate with Magellan in developing and carrying out a quality improvement plan should opportunities for improvement be identified. Maintain records for a period of at least five years from the date of service, or longer if required by law. Magellan s responsibility to you is to: Provide detailed information prior to the review concerning the rationale, methods and standards employed in the review process. Request the minimum necessary protected health information to perform treatment record reviews. Suggest steps to be taken to improve quality of treatment record documentation. Work collaboratively with you to create and implement a corrective action plan, if required. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 3-7

4. Quality Partnership Commitment to Quality Our Philosophy Our Policy What You Need to Magellan supports the delivery of quality care, with the primary goal of improving the health status of members and, where the member s condition is not amenable to improvement, maintaining the member s current health status by implementing measures to prevent any further decline in condition or deterioration of health status. This includes identifying members at risk of developing conditions, implementing appropriate interventions, and designating adequate resources to support the intervention(s). In support of our Quality Improvement Program, our providers are required to be familiar with Medicaid and Magellan guidelines and standards and apply them in clinical work with members. To comply with this policy your responsibility is to: Understand federal and state Medicaid standards applicable to providers. Comply with federal and state Medicaid standards. Provide input and feedback to Magellan to actively improve the quality of care provided to members. Participate in quality improvement activities if requested by Magellan. What Magellan Will Magellan s responsibility to you is to: Actively request input and feedback regarding member care. Work with members, providers, community resources and agencies to improve the quality of care provided to members. Operate a toll-free telephone hotline to respond to provider questions, comments and inquiries. Establish a multi-disciplinary Quality Oversight Committee to oversee all quality functions and activities. Maintain a health information system sufficient to support the collection, integration, tracking, analysis and reporting of data. Provide designated staff with expertise in Quality Assessment, Utilization Management and continuous Quality Improvement. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 4-1

4. Quality Partnership Cultural Competency Our Philosophy Our Policy What You Need to What Magellan Will Magellan is committed to embracing the rich diversity of the people we serve. We believe in providing high-quality care to culturally, linguistically and ethnically diverse populations, as well as to those who are visually and hearing impaired. All people entering the behavioral health care system must receive equitable and effective treatment in a respectful manner, recognizing individual spoken language(s), gender, and the role culture plays in a person s health and well-being. Magellan staff is trained in cultural diversity and sensitivity, in order to refer members to providers appropriate to their needs and preferences. Magellan also provides cultural competency training, technical assistance and online resources to help providers enhance their provision of high-quality, culturally appropriate services. Magellan continually assesses network composition by actively recruiting, developing, retaining and monitoring a diverse provider network compatible with the member population. Your responsibility is to: Provide Magellan with information on languages you speak. Provide Magellan with information about any practice specialty you hold on your credentialing application. Magellan s responsibility to you is to: Provide ongoing education to deliver competent services to people of all cultures, races, ethnic backgrounds, religions, and those with disabilities. Provide language assistance, including bilingual staff and interpreter services, to those with limited English proficiency during all hours of operation at no cost to the consumer. Provide easily understood member materials, available in the languages of the commonly encountered groups and/or groups represented in the service area. Monitor gaps in services and other culture-specific provider service needs. When gaps are identified, Magellan will develop a provider recruitment plan and monitor its effectiveness. Provide you with a hardcopy of our Cultural Competency plan if requested at no cost to you by contacting the Magellan Provider Services Line at 1-800-327-7921. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 4-2

4. Quality Partnership Provider Input Our Philosophy Our Policy What You Need to What Magellan Will Magellan believes that provider input concerning our programs and services is a vital component of our quality programs. Magellan obtains provider input through provider participation in various workgroups and committees of the Florida Care Management Center. We offer providers opportunities to give feedback through participation in our quality programs, or via requests for feedback in provider publications. To comply with this policy your responsibility is to: Understand federal and state Medicaid standards applicable to providers. Comply with federal and state Medicaid standards. Provide input and feedback to Magellan to actively improve the quality of care provided to members. Participate in quality improvement and utilization oversight activities if requested by Magellan. Provide timely information to support State reporting requirements. Magellan s responsibility to you is to: Actively request input and feedback regarding member care. Operate a toll-free telephone hotline to respond to provider questions, comments and inquiries. Establish a multi-disciplinary Quality Oversight Committee to oversee all quality functions and activities. Maintain a health information system sufficient to support the collection, integration, tracking, analysis and reporting of data. Provide designated staff with expertise in quality assessment, utilization management and continuous quality improvement. Develop and evaluate reports, indicate recommendations to be implemented, and facilitate feedback to providers and members. Participate in annual performance improvement projects (PIPs) that focus on clinical and non-clinical areas and provide annual reports on performance improvement project results using a valid process for evaluation of the impact and assessment of the quality improvement activities. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 4-3

4. Quality Partnership Member Action Appeal Process Magellan complies with Florida True Health s member grievance requirements, which includes a grievance process, an appeal process and, for Medicaid members, the availability to the Medicaid Fair Hearing and Subscriber Assistance Program. Magellan is not delegated grievances or member appeals with the exception of expedited/emergency appeals. Magellan is delegated provider complaints and provider appeals. All grievances and appeals (other than expedited appeals) filed on behalf of a member are managed by Florida True Health. A Member grievance or appeal can be filed verbally or in writing by contacting: Florida True Health Attention: Member Grievances & Appeals P.O. Box 7335 London, Kentucky 40742 Telephone: 1-866-423-1444 How to File an Expedited Action Appeal with Magellan (Member Expedited Action Appeal Process) Refer to the adverse determination notification (notice of action) letter for the specific procedures for appealing a Clinical Determination. Inform our members of their right to appeal and assist them during the appeal process, if applicable. Expedited Fast Track Action Appeal The member can ask for an expedited appeal if the member or the member s provider thinks that waiting up to thirty (30) calendar days could put the member s life or health in danger. If we deny your request for an expedited review, the Plan will let you know and immediately transfer the appeal to the timeframe for standard appeals. The member may request an expedited action appeal if: o The member received a denial of continued or extended health care services, procedures or treatments; o The member received a denial of additional services in a course of continued treatment; o The member s health care provider believes an immediate appeal is warranted; or o The standard appeal timeframe could seriously jeopardize the member s life or health, or ability to regain maximum function or subject the member to pain that cannot be managed adequately. An expedited action appeal can be filed verbally or in writing by the member, or the member s authorized representative, or the provider with the member s written consent. Expedited appeal requests should be filed by contacting: Magellan Behavioral Health, Inc. Attention: Grievance & Appeals Coordinator (Florida True Health) 7400 NW 19 Street Suite C Miami, FL 33126 1-800-327-7921 Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 4-4

4. Quality Partnership Member Action Appeal Process If the member chooses to submit an expedited action appeal by telephone, it does not have to be submitted in writing. The date of the verbal expedited action appeal request shall constitute the date of Magellan s receipt of the appeal. The member has the right to review the case file before or during the appeal process. The member may present/submit any information they think will support the appeal in person or in writing. If the member is not satisfied with the decision Magellan made regarding the expedited action appeal, please contact the Plan for information about additional appeal options that are available to you through the Plan. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 4-5

4. Quality Partnership Provider Complaints and Appeals Process Our Philosophy Our Policy In order to achieve a high level of provider satisfaction and care, Magellan believes in providing a mechanism for members, providers and external agencies to express comments related to care, service, or confidentiality. Magellan maintains processes for addressing verbal and written complaints. All provider complaints and appeals are received and processed by Magellan on behalf of Florida True Health. Magellan maintains a provider complaint system that permits a provider to dispute Magellan s policies, procedures, or any aspect of Magellan s administrative functions, including proposed actions and claims. This section is applicable to any complaint or appeal filed by a provider on the provider s own behalf, or by the provider s authorized representative. What You Need to To comply with this policy your responsibility is to: Know about the process for filing a complaint. How to File a Complaint (Provider Complaint Process) If a provider is dissatisfied with Magellan for any reason, the provider may file a complaint with Magellan. A provider complaint can be filed verbally or in writing by contacting: Magellan Behavioral Health, Inc. FL CMC Attention: QI Department / Provider Complaints & Appeals 7400 NW 19 th Street Suite C Miami, Florida 33126 1-800-327-7921 If the provider is not satisfied with the decision made by Magellan, a provider may file an appeal of a complaint resolution within forty-five (45) calendar days of receiving the notice of resolution. The forty-five (45) calendar days filing period is not applicable to claims-related appeals. To file an appeal, providers should submit the appeal in writing and must include all pertinent information that is relevant to the appeal. Provider must also submit a cover letter explaining the circumstances of the case and the reason that Magellan should change its initial decision. To the extent applicable, this letter must have at a minimum the member s name, policy number, type of service rendered and date(s) of service. Provider complaint appeals may be sent by fax to 305-717-5399, or by mail to the address above. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 4-6

4. Quality Partnership Provider Complaint and Grievance Process What Magellan Will Magellan will resolve the provider s complaint appeal and provide written notice of our decision within thirty (30) calendar days from when the complaint appeal was received by Magellan. Magellan maintains a record of provider complaints and appeals and submits reports as required by Florida True Health. Magellan is available to provide any assistance you may need with filing an action appeal. If you have any questions, please call 1-800- 327-7921. Our office hours are 8:30 a.m. to 5:30 p.m., Monday to Friday. For speech or hearing impaired, please call TTY 1-800-424-1694. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 4-7

4. Quality Partnership Member Rights & Responsibilities Our Philosophy Our Policy What You Need to What Magellan Will Magellan believes that all members should be informed of all types of available assistance. We are committed to respecting the dignity and worth of each member. We require providers to inform members about the availability of Consumer Assistance. To comply with this policy, your responsibility is to: Prominently display a Consumer Assistance Notice in reception area that is clearly noticeable by all covered members. o The notice must state the addresses and toll-free telephone numbers of AHCA, the SAP and the Dept of Financial Services. o Also, clearly state Magellan s address and toll-free telephone number. Magellan s responsibility to you is to: Make available all relevant addresses and toll-free telephone numbers. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 4-8

5. Provider Reimbursement- Professional Services Our Philosophy Our Policy What You Need to Magellan is committed to reimbursing our providers promptly and accurately, in accordance with our contractual agreements. Magellan reimburses behavioral health and substance abuse treatment providers in accordance with reimbursement schedules for professional services. The reimbursement schedules contain current procedural terminology (CPT ) codes for traditional outpatient providers and a combination of CPT and Healthcare Common Procedure Coding System (HCPCS) codes for Community Service Boards (CSBs). The reimbursement schedule(s) is attached to your Magellan provider agreement. Your responsibility is to: Contact Magellan at 1-800-327-7921 to check eligibility and obtain needed authorization for services. You also may complete this process online at www.magellanhealth.com/provider for nonroutine outpatient services that require authorization. Collect applicable co-payments from members. Contact Magellan at 1-800-327-7921 to verify eligibility, obtain copayment amount and pre-certify care for all higher levels of care. Sign up for online claims submission and electronic funds transfer (EFT) through www.magellanhealth.com/provider. Submit a clean claim form for the services that you have provided through www.magellanhealth.com/provider, through an accepted clearinghouse, or via paper claim. The postal address for claims is: Magellan Health Services P.O. Box 1429 Maryland Heights, MO 63043 In accordance with state requirements, Magellan requires Medicaid claims to be submitted by the 120 th calendar day, but no later than the 180 th calendar day from the date of service. Submit your claim for reimbursement within the limits required by the State. Magellan encourages providers to submit claims within 60 calendar days of date of service or discharge; however, claims will not deny until 181 calendar days from date of service or discharge. Submit a claim after the following has occurred: o Discharge for inpatient services or the date of service for outpatient services. Bill using your contracted Taxpayer Identification Number. Hold the member harmless and not bill the member for any amount, including the difference between Magellan s reimbursement amount and your standard rate. This practice is called balance billing and is prohibited. Contact Magellan at 1-800-327-7921 if you are not certain Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 5-1

5. Provider Reimbursement- Professional Services which services require prior-authorization, what your reimbursement rate is, or for any questions that you have concerning the member in care. What Magellan Will Magellan s responsibility to you is to: Pay your claims promptly: 20 days from the date the clean claim is received if submitted electronically and 40 days if paper claim is submitted via hardcopy, fax or mail. (see FS 641.3155 Prompt payment of claims). Provide a toll-free number for you to call for provider assistance (1-800-327-7921). Respond to your claims questions and help resolve issues. Review our reimbursement schedules periodically in consideration of Medicaid changes. Include all applicable reimbursement schedules as exhibits to your contract. Communicate changes to reimbursement rates in writing prior to their effective date. Notify you that we are authorized to take whatever steps are necessary to ensure that you are recognized by the state Medicaid program, including its choice counseling/enrollment broker contractor(s) as a participating provider and that your submission of encounter data is accepted by the Florida MMIS and/or the state s encounter data warehouse. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 5-2

6. Fraud, Waste and Abuse Report Suspected Fraud, Waste, Abuse, or Overpayments to Magellan Magellan expects providers and their staff and agents to report any suspected cases of fraud, waste, abuse, and overpayments. Magellan will not retaliate against you if you inform us, the federal government, state government or any other regulatory agency with oversight authority of any suspected cases of fraud, waste, abuse, or overpayments. Reports may be made to Magellan via one of the following methods: Special Investigations Unit Hotline: 1-800-755-0850 Special Investigations Unit Email: SIU@MagellanHealth.com Corporate Compliance Hotline: 1-800-915-2108 Compliance Unit Email: Compliance@MagellanHealth.com Reports to the Corporate Compliance Hotline may be made 24 hours a day/seven days a week. The hotline is maintained by an outside vendor. Callers may choose to remain anonymous. All calls will be investigated and remain confidential. Remember! Magellan will not retaliate against you or any of its employees, agents and contractors for reporting suspected cases of fraud, waste, or abuse to us, the federal government, state government, or any other regulatory agency with oversight authority. Federal and state law also prohibits Magellan from discriminating against an employee in the terms or conditions of his or her employment because the employee initiated or otherwise assisted in a false claims action. Magellan also is prohibited from discriminating against agents and contractors because the agent or contractor initiated or otherwise assisted in a false claims action. Report Suspected Fraud, Waste, Abuse, or Overpayments to Oversight Agencies You can also report suspected cases of fraud, waste, abuse, and overpayments directly to the agencies listed below. Florida Agency for Health Care Administration Bureau of Medicaid Program Integrity: Reports can be made to the Departments Consumer Complaint Hotline tollfree at 1-888-419-3456 or by completing a Medicaid Fraud and Abuse Complaint Form, which is available online at: https://apps.ahca.myflorida.com/inspectorgeneral/fraud_complaintform.aspx Florida Office of the Attorney General Medicaid Fraud Control Unit: Call the Attorney General toll-free at 1-866-966-7226. Those who report fraud may be entitled to a reward if they report a criminal case that results in a fine, penalty or forfeiture of property. Find out if you are eligible for a reward. Callers may request to remain anonymous. Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 6-1

6. Fraud, Waste and Abuse Florida Department of Financial Division of Insurance Fraud Contact the DFS Fraud Hotline at 1-800- 378-0445 U.S. Department of Health & Human Services Office of Inspector General: Contact the Office of the Inspector General at 1-800-447-8477 or by email to HHSTips@oig.hhs.gov or by mail to the address below. More information is available at: Office of Inspector General Department of Health & Human Services ATTN: HOTLINE PO Box 23489 Washington, DC 20026 http://ahca.myflorida.com/medicaid/abuse/index.shtml http://ahca.myflorida.com/executive/inspector_general/complaints.shtml https://oig.hhs.gov/fraud/ Magellan Behavioral Health of Florida 2013 Magellan Health Services Page 6-2