Frequently Asked Questions
Data System Transition for NBHS Services FAQ
Magellan FAQ for Members
Why does the Nebraska Department of Health and Human Services (DHHS) contract with Magellan Health Services?
Magellan is contracted by the Nebraska Divisions of Behavioral Health Services and Medicaid and Long-Term Care to manage publicly funded mental health, substance abuse and gambling addiction treatment for eligible children and adults across the state.
Why do these services need to be "managed"?
It is important that the limited funds allocated by the Nebraska Legislature for this purpose be used most effectively and efficiently. As a Managed Care Organization (MCO), Magellan is contracted to oversee the provision of mental health, substance abuse and gambling addiction treatment. Our goal is to be sure eligible individuals receive the right service, at the right time, with the right intensity.
What is an MCO?
A Managed Care Organization (MCO) is a group of health industry companies and professionals that work together to provide health care at affordable rates and at the same time control the costs of providing these services. As an MCO, Magellan's goal is to deliver high quality health care when it is medically necessary and to render the services by the most appropriate health care professional. Magellan will also oversee how health care professionals are reimbursed for their services.
How does Magellan authorize treatment services?
Treatment decisions are based on established clinical criteria for the various types of treatment available. Treatment services are authorized when the individual is determined to have a medical need for the service based on a match between his or her symptoms and the established clinical criteria. This is called "meeting medical necessity." Payments to Magellan for the services provided to DHHS remain the same regardless of Magellan's treatment authorizations.
What is Medical Necessity?
Magellan defines Medical Necessity as health care services and supports that are:
- medically appropriate;
- necessary to meet the basic needs of the member;
- rendered in the most cost-effective manner and in the type of setting appropriate for the delivery of the covered service;
- consistent in type, frequency and duration of treatment with scientifically based guidelines of national medical research or health care coverage organizations or government agencies;
- consistent with the diagnosis of the condition;
- required for means other than the diagnosis of the member;
- no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness and efficiency;
- of demonstrated value; and
- delivered at a level of service no more intense than can safely be provided.
What does the term "Prior Authorization" mean?
Prior authorization is an expectation that Magellan has for most services in order to process a provider's claims. "Prior Authorization" means that all services must be reviewed and an authorization completed by Magellan prior to or at admission for all services. All requests for authorization must meet the state's medical necessity "clinical criteria" to be approved for payment.
How are the Clinical Criteria developed?
The State of Nebraska DHHS developed its Clinical Criteria based on input from medical leadership and individual community providers. Magellan has adopted the criteria in their entirety for consistent use in administering the MCO functions for DHHS. The Clinical Criteria are available for viewing on the Magellan Web site at www.MagellanHealth.com/Provider as Appendix C of the Provider Handbook.
How does the education and training of Magellan staff prepare them to make determinations of medical necessity?
The individuals who fill the care manager roles at Magellan are mental health practitioners and registered nurses licensed by the State of Nebraska. Some of these individuals have dual licensure in substance abuse services. Magellan supports care managers in maintaining their licensure and their receipt of the most current information available to the field through ongoing internal and external training. Care managers authorize mental health and substance abuse treatment services when the client meets the definition of medical necessity. Only a psychiatrist licensed in the State of Nebraska and employed or contracted by Magellan can deny services.
If a request for service is denied by Magellan, what recourse does the client or provider have?
Clients and their providers have access to the Magellan appeals process. The entire appeals process can be viewed as a work flow on the Magellan Web site at www.MagellanHealth.com/Provider as Appendix D of the Provider Handbook.
Do network providers have a voice with Magellan?
Magellan has developed a Provider Advisory Group (PAG) to increase collaboration with providers who are serving Magellan members. Through the PAG, Magellan solicits providers' feedback to identify and help implement process changes prior to implementation, and invites them to provide their recommendations for clinical practice guidelines, medical necessity criteria, coordination of care initiatives and clinical outcomes. The PAG will review Magellan's annual member and provider satisfaction survey results and offer recommendations on provider training opportunities and an annual provider relations plan.
Magellan also hosts the "Quarterly Organizational Roundtable" and the quarterly "Provider Forum" to share information with and solicit information from providers.
What about providers who do not contract to provide Magellan services?
Magellan manages only the network of providers in Nebraska who are enrolled with Nebraska Medicaid to provide mental health, substance abuse and gambling addiction services. Providers of services must be enrolled with Medicaid and contracted with Magellan in order to obtain service authorizations and subsequent payment from DHHS.