West Virginia Medicaid 2010 Authorization Flowcharts

1. West Virginia Medicaid 2010 Authorization Flowcharts

2. Routine Outpatient Preauthorization Request Provider submits Header File and Service Request to APS APS sends Header File and Service Request to MBH via FTP MBH pulls applicable data elements from Header File and Service Request MBH reviews member eligibility MBH reviews data to determine authorization package Info Needed? MBH contacts provider for additional clinical Yes No MBH authorizes services Auth letter sent to the provider Provider gives additional clinical • MBH Network Contact– Susan Jameson • 678-319-3903 • MBH Customer Service– 800-327-4574 • MBH Website – www.magellanprovider.com Confidential Magellan Health Services

3. Routine Outpatient Concurrent Request Provider submits Header File and Service Request to APS APS sends Header File and Service Request to MBH via FTP MBH pulls applicable data elements from Header File and Service Request MBH reviews member eligibility MBH reviews data to determine concurrent authorization package MBH contacts provider for additional clinical MBH authorizes services Auth letter sent to the provider Yes Info Needed? No Provider gives additional clinical • MBH Network Contact– Susan Jameson • 678-319-3903 • MBH Customer Service– 800-327-4574 • MBH Website – www.magellanprovider.com Confidential Magellan Health Services

4. Routine Inpatient Preauthorization Request Facility contacts MBH telephonically to request an inpatient admission • MBH Network Contact– Susan Jameson • 678-319-3903 • MBH Customer Service – 800-327-4574 • MBH Concurrent Reviewer– provided during call • MBH Website – www.magellanprovider.com MBH reviews member eligibility Member case created in clinical system Caselogix algorithm launched Caselogix Criteria Met? Auth letter sent to provider MBH authorizes services Facility contact is transferred to MBH CM Yes No MBH CM collects additional clinical information Inpatient Criteria Met? MBH CM approves Admission Yes No Facility instructed to call back with additional clinical detail Insufficient clinical MBH CM confirms approved length of stay, and concurrent review contact information No Clinical does not appear to meet MNC *Concurrent CM/Facility contact to be made within 24 hours of last covered day PA contacts facility for additional clinical Inpatient Criteria Met? Facility notified verbally – member and facility notified in writing MBH authorizes services Yes No Confidential Magellan Health Services

5. Routine PHP Preauthorization Request Provider contacts MBH telephonically for Partial Hospitalization pre-authorization • MBH Network Contact– Susan Jameson • 678-319-3903 • MBH Customer Service – 800-327-4574 • MBH Concurrent Reviewer– provided during call • MBH Website – www.magellanprovider.com MBH reviews member eligibility Member case created in clinical system Provider is transferred to MBH CM MBH CM collects clinical data PHP Criteria Met? MBH CM approves PHP Provider instructed to call back with additional clinical detail Yes No Insufficient clinical MBH CM confirms approved initial authorization and concurrent review contact information No *Concurrent CM/Facility contact to be made within 24 hours of last covered day Clinical does not appear to meet MNC PA contacts provider for additional clinical Provider notified verbally – member and provider notified in writing PHP Criteria Met? MBH authorizes services Yes No Confidential Magellan Health Services

6. Routine Inpatient Concurrent Request Facility contacts MBH telephonically to request continued inpatient stay MBH reviews member eligibility MBH CM collects clinical data Continued Stay Criteria Met? MBH CM approves continued stay Yes No Facility instructed to call back with additional clinical detail Insufficient clinical MBH CM confirms approved length of stay No *Concurrent CM/Facility contact to be made within 24 hours of last covered day Clinical does not appear to meet MNC PA contacts facility for additional clinical Continued Stay Criteria Met? Facility notified verbally – member and facility notified in writing MBH authorizes services Yes No • MBH Network Contact– Susan Jameson • 678-319-3903 • MBH Customer Service – 800-327-4574 • MBH Concurrent Reviewer– provided during call • MBH Website – www.magellanprovider.com Confidential Magellan Health Services

7. Routine PHP Concurrent Request Provider contacts MBH telephonically to request continued PHP treatment MBH reviews member eligibility MBH CM collects clinical information PHP Criteria Met? MBH CM approves Additional PHP days Yes No Provider instructed to call back with additional clinical detail Insufficient clinical MBH CM confirms approved days No *Concurrent CM/Facility contact to be made within 24 hours of last covered day Clinical does not appear to meet MNC PA contacts facility for additional clinical PHP Criteria Met? Provider notified verbally – member and provider notified in writing MBH authorizes services Yes No • MBH Network Contact– Susan Jameson • 678-319-3903 • MBH Customer Service – 800-327-4574 • MBH Concurrent Reviewer– provided during call • MBH Website – www.magellanprovider.com Confidential Magellan Health Services

8. Inpatient Partial Hospitalization Intensive Services Routine Outpatient Higher Levels Of Care Magellan will conduct clinical transition of care calls with the Facilities and take responsibility for members upon step down to a lower level of care Transition Of Care • Outpatient and Other Services • Requirement for authorization is waived during the first 90 days of the program • During this period, covered outpatient services will be paid at a) contracted provider rate or b) state rate for non contracted providers • Magellan would not require an authorization for outpatient services during this 90 day period • After the first 90 days of the program, Magellan allows the provider 14 days to submit their request for authorization Confidential Magellan Health Services

9. Paper Claims are mailed to Magellan. Once received, claims are imaged and loaded into Magellan’s claims system, CAPS. Clearinghouse Provider sends claims to a clearinghouse. The clearinghouse images the claims and sends them to Magellan via EDI. Direct Submit Claims can be submitted directly to Magellan through a secure FTP server or posted directly to Magellan’s Web site. Claims Courier Professional claims (CMS 1500) are submitted electronically on Magellan’s Web site using the Claims Courier application. Magellan Receives and Processes Claims at Our Midwest CMC P.O. Box 1928 Maryland Heights, MO 63043 Paper Claims Paper claims are scanned into the imaging system. Claims eligible for auto-adjudication are entered into the auto-adjudication program. Claims not eligible for auto adjudication are routed to the appropriate unit for online adjudication Electronic Claims Claims received electronically are loaded into the system and run through the adjudication process • Adjudication Process • Eligibility Edits • Benefits Edits • Provider Edits • Provider Rates Edits • Accumulator Edits • TPL / COB Edits Final disposition (pay / deny) sent to Provider / Member Yes Is Provider signed up for EFT? No Electronic Notification (EFT) sent to Provider and monies are transferred to Provider’s bank Check generated and sent to Provider Electronic Remittance Advice (EFA) sent to Provider Is Provider signed up for Electronic Remittance Advice (ERA)? Paper notification (EOP ) sent to Provider Yes No Confidential Magellan Health Services

10. Web Site Tools 24/7 Access • Eligibility Inquiry • Authorization Inquiry • Claims Inquiry • Claims Courier (CMS-1500 Submission) • Electronic Funds Transfer (EFT) Registration • Check Network Status • Update Provider Profile • Online Provider Orientation • Online Re-Credentialing Application • Outcomes Reports • Free CEUs • Provider Handbook • Provider Focus Newsletter • Medical Necessity Criteria • Clinical Practice Guidelines Confidential Magellan Health Services

11. Online Resources for Providers • On the Education section go to Online Training to view Website User Guides and Demos of Online Tools. • Website User Guides: on authorizations/eligibility, claims, electronic transactions, etc. https://www.magellanprovider.com/MHS/MGL/userguides/index.asp • Demos of Online Tools: https://www.magellanprovider.com/MHS/MGL/education/online_training.asp • View authorizations, claims demo, entire electronic transactions demo, etc. • How to View Authorization Letters Website User Guide:  https://www.magellanprovider.com/MHS/MGL/userguides/userguide_viewauthletters.pdf • View Authorizations Demo: https://www.magellanprovider.com/MHS/MGL/education/Demos/ViewAuth/ViewAuth.html Confidential Magellan Health Services