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For Providers

Clinical Appeals

What You Need to Do

Refer to the Notice of Action (non-authorization) letter for the specific procedures for appealing a clinical determination; however,

  • Clinical Appeals must be requested within 30 calendar days from the date of the Notice of Action letter.
  • The provider or facility may only appeal on behalf of the member if they have obtained the member’s written consent, which must be submitted with the appeal request. Also, written consent must be obtained after an adverse decision has been issued in a case.
  • Oral requests for standard appeals must be followed by a written and signed request, unless expedited.

What Magellan Will Do

  • Allow you, the member, or the member’s authorized representative to file an appeal after receiving the Notice of Action. The appeal must be filed within 30 calendar days of the date of the Notice of Action.
  • Allow you to expedite the appeal when you or the member indicate that the time it would take to complete a standard appeal would seriously jeopardize the member’s life, health, or ability to attain, maintain or regain maximum function. Expedited appeals will be completed and verbal and written notification sent with 72 hours of the request.
  • Process the appeal as a standard appeal, if an expedited appeal is not requested or is not warranted based on the facts. A Notice of Appeal Resolution of a standard appeal will be mailed within 30 calendar days of the initial request for appeal.
  • Extend the timeframe for completing appeals by up to 14 calendar days at the request of the member, the provider or Magellan.
  • Notify you of the appeal decision, as well as the State Fair Hearing process. The member must exhaust all internal appeal processes prior to requesting a State Fair Hearing.
  • All requests for a State Fair Hearing should be sent to:

Division of Administrative Law
Health and Hospitals Section
P.O. Box 4189
Baton Rouge, LA 70821-4189

  • Staff all appeals with individuals who have the appropriate clinical experience and who have not been previously involved in the decision (for medical necessity appeals or appeals involving other clinical issues).
  • Accept information from the member and his/her representative (generally including the facility and provider) to support the request for appeal and allow the member to examine his/her case file (including medical records and other documents considered during the appeal) before and during the appeal process.
  • Not take any punitive action against any provider that requests or supports an appeal.
  • Review services retrospectively as long as it is clear that the provider had no way of knowing that the member was eligible for services under Magellan. If eligibility is established retrospectively by the state, we will complete a clinical review; however, that does not mean that services will be authorized, as it is required that the services be medically necessary. Requests for retrospective reviews should be submitted to Magellan no later than 365 days after the date of service.

 

This guidance, as well as other important information for all network providers is located at Magellan Provider Handbooks and Supplements.


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