Provider materials and tools

Policy update: Prior authorization required on claims

Appealing a claim denied for lack of prior authorization

Effective November 1, 2018, Magellan Complete Care will no longer retroactively review claims with medical records without the required prior authorization. If a provider chooses to appeal a claim that has been denied due to not requesting and/or receiving prior authorization, the administrative denial will be upheld through appeal, regardless if medical records were provided.

If the appealing provider informs Magellan Complete Care that the denied claim relates to a true medical emergency, we will make the exception and perform the clinical review with the medical records attached to the claim in question.

Please note: True medical emergencies are the only exceptions where Magellan Complete Care will perform clinical reviews without the required prior authorization. If the appealing provider fails to note that the denied claim relates to a true medical emergency, no clinical review will be performed and the denial will be upheld for lack of prior authorization.

 

Prior authorization is required for certain services

Certain services require prior authorization from our Utilization Management (UM) department. You can find a list of the services that are affected by this requirement as well as more information about prior authorization on our website. You can also view and print the Prior Authorization form online and fax it to our UM staff at 1-888-656-4083. Please be sure to put the fax to the attention to: The Utilization Management Department. Prior authorization requests can even be made over the phone by calling UM at the numbers listed at the end of this bulletin.

 

Listing prior authorization approval numbers on your claim speeds up processing

Once you have received prior authorization, please remember to:

  • Include the prior authorization approval number on the claim form that you submit to Magellan Complete Care for reimbursement of services.
  • If using CMS1500 professional claim form, enter PA number in Box 23
  • If using CMS1450 (UB-04) institutional claim form, enter PA number in Box 63

Please note: It is important that you include the prior authorization approval number on your submitted claim. Failure to do so will cause a delay to the approval of your claim and payment due to the manual processing of your claim.

 

Contact us for more information

If you would like to request prior authorization, please contact the UM staff at the following numbers:

1-800-327-8613

 

Important fax numbers

 

Prior authorizations

Elective prior authorization requests and provider correspondence

1-888-656-4083

 

Concurrent reviews

Inpatient Admissions

1-888-656-4894

 

Appeals

Medical records and corresponding appeal summaries

1-888-656-4864

 

Care coordination

Care integration, communication tools and documents

1-888-656-6164

 

If you have any questions please call us at 1-800-327-8613.

 

posted on 9/27/2018