Magellan Complete Care of Florida (MCC of FL) has adopted MCG Guidelines® to guide utilization management decisions as well as develop and maintain proprietary clinical criteria and behavioral healthcare guidelines for specialty behavioral outpatient services and specific Florida Medicaid services. MCC of FL follows Florida Medicaid policies and the Agency’s criteria and definition of medical necessity as it is written in the Florida Administrative code (See Rule 59G-1.010).
Other medical necessity criteria and considerations are based on characteristics of the local delivery systems available for specific enrollees along with enrollee-specific factors such as the enrollee’s age, co-morbidities, complications, progress in treatment, psychosocial situation and home environment.
Utilization management decisions may include, but are not limited to:
- Decisions involving pre-certification
- Inpatient review, level of care
- Discharge planning
- Retrospective review
The MCG Guidelines® license includes:
- Inpatient & Surgical Care Guidelines
- General Recovery Care Guidelines
- Ambulatory Care
- Recovery Facility Care
- Home Care
- Behavioral Health Care
- Multiple Condition Management
Coverage decisions are subject to all terms and conditions of your benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law.
Clinical UM guidelines can be highly technical and complex, treating health care providers should discuss the information in the clinical UM guidelines with their patients.
These criteria are made available upon request. The MCG Guidelines® are proprietary and are not published online. If you would like to request a hard copy of an individual guideline, please call us at 1-800-327-8613.
Our Model of Care
MCC of FL providers are the key to our success in meeting the needs of our members. Our model of care is built to meet the medical and behavioral healthcare needs of our members. The level of support and coordination is dependent on the needs of the individual members.
Outcomes of the MCC of FL model of care:
• Better overall health and wellness
• Better sustained care
• Reduced length of stay
• Reduced emergencies of all kinds
• Reduced burdens on medical, community and municipal resources
Our core care team’s high-touch management helps members:
• Make appointments
• Arrange transportation to appointments
• Adhere to treatment regimens
Our Care Coordination Team
- The integrated care case manager (CM) is either an RN or a licensed mental health professional that is in charge of putting together the care plan, coordinating care, assisting members with complex situations and providing face-to-face help.
- The health guide is the member’s advocate, helping them navigate the health care system and keep doctor appointments, and coordinating with community agencies and other resources.
- The primary behavioral health provider is responsible for overseeing the delivery and quality of behavioral health services.
- The primary medical provider oversees medical services to ensure they are medically correct and coordinated.
- The medical specialist helps when the member has a complex medical condition.
- The peer support specialist provides emotional support to inspire hope for the future.
Our team of pharmacists review medication usage as needed.
- Family members, caregivers and other individuals/agencies involved in care may all be included to help support the member
MCC of FL’s medical necessity criteria (MNC) are based on current scientific evidence and clinical consensus that are used in making medical necessity determinations. We review the criteria annually, considering current scientific evidence along with provider feedback, and revise as needed. We also align these criteria with the Agency for Healthcare Administration’s medical necessity standards and practice protocols.
Can a non-participating provider give treatment or provide services to an MCC of FL member?
A non-participating provider is a provider who’s not in a contractual agreement with Magellan Complete Care of Florida (MCC of FL).
MCC of FL allows members to receive medically necessary services and treatment from a non-participating provider if the service can’t be provided by a provider in the MCC of FL network.
MCC of FL will reimburse non-participating providers based on the Medicaid fee schedule rate for claims submitted.
To ensure timely payment, MCC of FL providers must submit clean claims using the correct codes for services provided. All claims must be submitted correctly as they provide the documentation needed for gaps in care for our members and for HEDIS (Health Plan Employer Data and Information Set).
Appeals or reconsiderations
To request an appeal or reconsideration, medical records must be accompanied with one of the following:
• A detailed cover letter to include the items specified in the Provider Appeals form. The cover letter must identify why the medical records were sent as well as a clinical summary of the provider’s rebuttal with references to national criteria such as; Interqual and/or Milliman –or
• A complete and detailed Provider Appeals form (additional pages can be attached)
Inpatient Hospital Days Benefit Exhaustion Medical Necessity Reviews
Medical records submitted for those aged 21 years and older for emergency services due to being over the inpatient hospital days benefit limit must be submitted as follows:
- A cover letter that must state that the facility is requesting a review for days they deem they provided emergency services. The cover letter must also include the dates that the hospital is seeking reimbursement, as well as an explanation indicating that the absence of immediate medical attention on those days would result in the following:
- Placing the health of the individual (or, for a pregnant woman, the health of the woman or her unborn child) in serious jeopardy
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part
- Medical Records should include the History and Physical, Discharge Summary, Physician’s Order and Progress Notes. It is not necessary to send nurses’ notes or pages of medications that the member received in the hospital. More information regarding appeals and grievances can be found in your Provider Handbook.
MCC of FL does not tolerate fraud, waste or abuse, by providers or staff.
We have extensive fraud, waste and abuse programs to combat these problems. MCC of FL’s programs are wide-ranging and multi-faceted, focusing on prevention, detection and investigation of all types of fraud, waste and abuse in government programs and private insurance.
MCC of FL’s expectation is that providers will fully cooperate and participate with its fraud, waste and abuse programs. This includes, but is not limited to:
- Permitting MCC of FL access to member treatment records
- Allowing MCC of FL to conduct on-site audits or reviews
- MCC of FL may also interview members as part of an investigation, without provider interference
The provider’s responsibility is to:
- Comply with all laws and MCC of FL’s requirements
- Comply with all federal and state laws regarding fraud, waste and abuse
- Provide and bill only for medically necessary services that are delivered to members in accordance with MCC of FL’s policies and procedures and applicable regulations
- Ensure that all claims submissions are accurate
- Notify MCC of FL immediately of any suspension, revocation, condition, limitation, qualification or other restriction on the provider’s license, or upon initiation of any investigation or action that could reasonably lead to a restriction on the provider’s license, or the loss of any certification or permit by any federal authority, or by any state in which you are authorized to provide healthcare services
More information regarding fraud, waste and abuse can be found in your Provider Handbook.