Provider tools

Utilization Management

The Utilization Management Department performs many functions including concurrent review, prior authorization, discharge planning assistance, retrospective review and other activities. Our Utilization Management program has the goal of optimizing the use of health care resources for our members. Services provided are not less than the amount, duration, and scope for the same services delivered to fee for service (FFS) Medicaid members. Medically necessary services are no more restrictive than used in the State defined program. Magellan Complete Care of Virginia makes the utilization management criteria available in writing, by mail, or fax. Magellan Complete Care of Virginia supports continuity and coordination of care for physical, dental, and behavioral health providers. Our members’ health is always our number one concern.

Mail:

Magellan Complete Care of Virginia
Attn: Utilization Management Department
3829 Gaskins Road
Glen Allen, VA 23233

Fax: 

CCC Plus: 1-866-210-1523
Medallion 4.0: 1-855-769-2116


Utilization management forms

Utilization management team members contact

Providers can call our toll free number at 1-800-424-4524 for CCC Plus and 1-800-424-4518 for Medallion 4.0 with any utilization management questions:

  • Our MCC of VA team members are available for incoming calls from 8 a.m. to 6 p.m. Eastern Standard Time (EST), Monday through Friday
  • Our MCC of VA team members can receive incoming calls regarding utilization management concerns after normal business hours
  • Our MCC of VA team members can send communications out regarding questions during normal business hours, unless otherwise agreed upon
  • Our MCC of VA team members are available to accept collect calls
  • Our MCC of VA team members will identify themselves by name, title and our organization name of MCC of VA when initiating or returning calls
  • Our MCC of VA team members are available to callers who have questions about the utilization management processes
  • Providers can leave voice mail messages after business hours, 24 hours a day and 7 days a week
  • A utilization management dedicated fax line can be used to submit requests for medical necessity determinations 24 hours a day and 7 days a week
  • An after hours, on call nurse is available for emergent/urgent concerns

Member support services

Our Member Services staff is available to help our members if they have any questions about their benefits, services, procedures, including questions regarding utilization management or have a concern about Magellan Complete Care of Virginia.

  • Member services staff are available Monday through Friday from 8:00 a.m. until 8:00 p.m. Eastern Standard Time (EST). Members can leave a voice message during non-business hours. We suggest our members leave a voice message with their question if it can wait until the next business day.
  • Members may access Member Services by calling our toll-free number, 1-800-424-4524 (TTY 711) for CCC Plus and 1-800-424-4524 (TTY 711) for Medallion 4.0, local time, from 8 a.m. to 8 p.m.
  • Magellan Complete Care of Virginia offers free interpreter services to the member. As a provider, you are required to identify the need for interpreter services for your Magellan Complete Care of Virginia patients and offer assistance to them appropriately.


Medical necessity criteria

Magellan Complete Care of Virginia utilizes nationally recognized criteria, MCG, to determine medical necessity and appropriateness of care. The criterion used is designed to assist clinicians and providers in recognizing the most effective health care practices used today which ensures quality of care to our members. This criteria is not intended to serve as a set of rules or as a replacement for a physician’s medical judgment about their patient’s health care needs. Magellan Complete Care of Virginia defaults to all applicable state and federal guidelines regarding criteria for authorization of covered services. Magellan Complete Care of Virginia also has polices developed to complement nationally recognized criteria. If a member’s clinical documentation does not meet the criteria, the case is forwarded to a Magellan Complete Care of Virginia Medical Director for further review and determination. The Magellan Complete Care of Virginia Medical Directors are available to discuss individual cases with attending physicians upon request.

Utilization review determinations are based only on appropriateness of care, service, and benefit coverage. Magellan Complete Care of Virginia does not reward providers or any staff members for adverse decisions for coverage or services. There are no financial incentives for our staff members that encourage them to make decisions that result in underutilization.

Upon request, Magellan Complete Care of Virginia will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling 1-800-424-4524 for CCC Plus or 1-800-424-4518 for Medallion 4.0; or faxing the Utilization Management Department at 1-866-210-1523 for CCC Plus or 1-855-769-2116 for Medallion 4.0. If you would like to discuss an adverse decision with Magellan Complete Care of Virginia’s Medical Director, please call the Utilization Management Department within five (5) business days of the determination.

Post stabilization services

Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting. To request authorization for an inpatient admission or have any questions related to post-stabilization services, please contact the Utilization Management Department at 1-800-424-4524 for CCC Plus or 1-800-424-4518 for Medallion 4.0.

 

 

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