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Magellan Complete Care of FloridaProvider TrainingConducted By:

Magellan Complete Care Provider Training AgendaWelcome and IntroductionsSatisfaction Surveys and QualityImprovement ActivitiesModel of Care and GoalsMember BenefitsCustomer Service andInterdisciplinary Care TeamMember Eligibility and PriorAuthorizationFraud Waste and Abuse2Claims, Billing and AppealsComplaints and GrievancesResources and ContactInformation

Magellan Complete Care of FloridaMagellan Complete Care of Florida is a specialty health plan designedspecifically for members living with serious mental illness who areeligible for Medicaid benefits.It promotes a fully integrated and coordinatedbehavioral health and physical health approachthat spans the continuum of care.MedicaidOUR GOALS: To ensure that all members receivepersonalized, high‐quality healthcare tailored to their medical,mental health, and social needs. Improve the overall health, longevityand well‐being of members. Lower the cost of care by providingbetter access and care coordinationfor this special population.3CompleteCareof FloridaChronicHealthConditionSeriousMentalIllness

Magellan Complete CareNetwork, Customer Serviceand Interdisciplinary Care Team

Network of Specialist and VendorsMCCFL has created a provider network ofqualified providers who are licensed andcompetent and have completed a formalcredentialing review. ProvidersAll providers must have a FL Medicaid numberand must be contracted with Magellan CompleteCare or with Magellan Behavioral Health witha Medicaid HMO Amendment. FacilitiesAll facilities must have a FL Medicaid numberand be contracted with Magellan Complete Careunless a Prior Authorization has been obtained.To find a participating facility orphysician please visitMagellanCompleteCareofFL.comor contact Provider Services at1‐800‐327‐86135

Network of Specialist and VendorsMagellan CompleteCare NetworkProviders (Medical)MagellanBehavioral Health(Behavioral Health)National ImagingAssociates(Radiology/Imaging)Magellan Rx(Pharmacy)OTHER: Chiro Alliance(Chiropractic Network) Hear USA (Hearing Aidsand Tests) Mom’s Meals (Post DischargeMeals) Coastal Care Services(Home Health & DME) ILS (Independent LivingSystems) NIA (Lab Vendor) DentaQuest (DentalServices) US Managed Care (ALFs/SNFs)PNS/DNS/ONS(Podiatry/Dermatology/Ortho) LabCorp (Lab Vendor) Florida Eye (OptometryServices) (Areas 10, 11) Veyo, LLC (Transportation)Premier Eye Care (OptometryServices (Areas 2,4,5,6,7,9) Quest (Lab Vendor) 6

Magellan Complete Care Customer Service Center Customer Service Center, available Monday throughFriday 8am – 7pm: 1‐800‐327‐8613 The following are examples of informationwhich can be obtained from accessingthe Magellan Complete Care website:www.MagellanCompleteCareofFL.com Eligibility Authorization request forms Claims Benefits PCP and provider information Interpretation ServicesIMPORTANT NUMBERS: After Hours AccessNurse Line Emergencies: 1‐800‐327‐8613 TTY: 1‐800‐424‐16947

Field Positions and their ResponsibilitiesNetwork Team Owns provider contractingrelationships Monitors Provider access Contracts with Providers Initiates Credentialing Process Processes signed agreements Responsible for provider In Servicesactivities Identifies and resolves provider issues Adds providers to the CAP claimsystem Handles Add/Changes and Deletes forproviders Member engagement and retentionactivitiesProvider SupportSpecialists and ProviderRelations Managers Builds and maintains positive relationships withproviders Partners with other departments Supports process that addresses providercomplaints, claims, credentialing Orientation, training, education to providers toimprove quality, outcomes and efficiencies andadoption of best practices Brokers relationships between behavioralhealth and physical health providers Performs Medical record review Assess practice readiness for working withmembers Rolls out Provider incentive programsCommunityOutreachSpecialistsHealthGuides Serves as the liaison to communitybased organization Expert on Medicaid programs andbenefits Complete community assessments toidentify strengths, needs and possiblepartnerships Build and maintain communityresources for the enrollees Planning and participation incommunity events and health fairs Presentations regarding communityresources Follow Medicaid Marketing guidelines Member engagement and retentionactivities Establishes a relationshipwith the enrollee, the carecoordination team, andhis/her providers Completes individualmember assessment (suchas Health and WellnessQuestionnaire (HWQ), NewEnrollee Interview) Tracks and coordinates careto ensure member isreceiving services Makes referrals to casemanagers and communityprograms and services, asneeded Member engagement andretention activitiesPeer SupportSpecialistsIntegrated Care CaseManagersWellnessSpecialistsCareWorkers Accountable for engaging members intheir care and supporting recovery‐based approaches Acts as a role model for healthybehaviors and lifestyles across themembership by sharing livedexperience with recovery, resiliency,and self‐directed care Leads Wellness Recovery Action Plan(WRAP) groups, collaborates inimplementing all health servicesprograms, and provides perspective asa member of the care coordinationteam Member engagement and retentionactivities Maintains a caseload of highly complexenrollees in the case management program Responsible for providing both behavioral andphysical case management services to members,providing clinical expertise for care coordinationteams, and facilitating an integrated approachto care delivery with providers, health homes,enrollees, their families, and communityagencies and services Coordinates complex care arrangements toensure quality and efficiency of care andachieve best possible outcomes Member engagement and retention activities Works with members on developingskills and confidence in selfmanagement of chronic conditionsand healthy lifestyles (tobacco orhealthy eating, for example) Oversees disease management plansfor members with a targeted chroniccondition Motivates enrollees to learn andadopt self‐management techniques tomaintain their health and wellness Designs and conducts group programsand workshops for enrollees, theirfamilies and supports Member engagement and retentionactivities Facilitates Health Servicesdepartment workflow Locates community servicesand other referral locationsfor enrollees, arrangesaccess to care Supports correspondence,other communications Member engagement andretention activities8

Magellan CompleteCare Member Eligibilityand Prior Authorization

Magellan Complete Care Eligibility Verification and ID CardYou may verify eligibility through web portal: www.MagellanCompleteCareofFL.comCall Magellan Complete Care member services line: 1‐800‐327‐861310

Magellan Complete Care Prior Authorization Prior Authorization lists MCCFL Provider Site MCCFL Participating Provider PriorAuthorization Guide MCCFL Quick Authorization Form11

Magellan Complete Care Prior AuthorizationAuthorization Requirementsand Medical Necessity Clinical practice guidelines Define services which require priorauthorization Availability of Peer to Peer discussionbefore determination is madeObtain prior authorization bycalling 1‐800‐327‐8613Pharmacy Most drugs on the Preferred Drug List(PDL) are available without priorauthorization. For drugs not on thePDL, a prior authorization is required. Medicaid Pharmacy Wrap benefit isprocessed through MMA 12MMA Pharmacy Helpdesk (providers)1‐800‐327‐8613Decision Timelines(AHCA standards) Standard 14 days Expedited 72 hoursConcurrent Inpatient notification only Please note, while the decisionstimelines noted above are contractual,our average turnaround time forstandard is 7 days and for expeditedcases it is within 48 hours, upon receiptof complete records. Behavioral Health professional servicesdo not need a Primary Care Physicianreferral for members Specialists need to contact PCP toobtain referral information and NPI

Magellan Complete Care Prior AuthorizationsContinuation of Care MCC will honor any written documentationof prior authorization of ongoing coveredservices for a period of sixty (60) calendar daysafter the effective date of enrollment, or until themember PCP or behavioral health provider (asapplicable to medical care or behavioral healthcare services, respectively) reviews the member’streatment plan, whichever comes first. MCC will not delay service authorizationif written documentation is not available in atimely manner; however, MCC is not required topay claims for which it has received no writtendocumentation.13 For all members, written documentationof prior authorization of ongoing medicaland behavioral health services includes thefollowing, provided that the services wereprearranged prior to enrollment with MCC:(1) Prior existing orders;(2) Provider appointments, e.g. dentalappointments, surgeries, etc.; and(3) Prescriptions (including prescriptionsat non‐participating pharmacies).

Magellan Complete Care Prior Authorizations Inpatient Admissionsthrough the (ER) Hospitals are required to notifythe Plan of all emergency inpatientadmissions within 24 hours. Retrospective Reviews A request for coverage of medical careor services that have been receivedand provider failed to request anauthorization / notification.14 Retrospective ReviewProcess for Services RequiringPrior‐Authorization Participating Providers‐ Retrospective review is not availablefor outpatient and electiveambulatory or inpatient servicesthat required prior authorization forwhich precertification did not occurbefore providing the service.

Magellan Complete CareSatisfaction Surveys andQuality Improvement Activities

AHCA Contract Compliance andQuality Improvement ActivitiesPerformanceImprovementProjects (PIPs) Improve Diabetes Screening Rates for People 18 years or olderwith Schizophrenia or Bipolar Disorder who are UsingAntipsychotic Medications in Florida Regions 10 and 11Percentage of Members 1 to 20 Years of Age That Had At LeastOne Preventive Dental Service During the Measurement YearImproving Plan All‐Cause Readmissions for Magellan CompleteCare MembersIncrease the Rate of Adult Member’s Overall Satisfaction ofMagellan Complete Care (CAHPS)Medical RecordReview (MRR) Record reviews are completed on an ongoing basis throughout the year.Providers are selected based on re‐credentialing date and high utilization.Five to ten records are reviewed for each provider.SatisfactionSurveys ProviderEnrollee (CAHPS)16 CCM SurveyDM Survey

Magellan Complete CareMember Benefits

Magellan Complete Care of Florida Member BenefitsDiseaseManagementPrograms Medical,Behavioral Health,PrescriptionDrugs, Dental,Vision,Transportation PreventionProgramsPlus, Enhanced Benefits, where members can earn creditfor participation in specific health activities. For moreinformation please check out our website.18

Summary of BenefitsVisit our website to learn more about the benefits available to members, at:www.MagellanCompleteCareofFL.com1919

Magellan Complete CareClaims, Billing and Appeals

Magellan Complete Care Claims Submission and Billing All providers must be credentialedprior to seeing patients, or claims willbe denied. Claims must be submittedwith the appropriate rendering providerinformation, including the full name ofthe rendering practitioner, servicelocation and NPI number. Organizations must submit to MagellanComplete Care a roster of renderingproviders by location on a monthlybasis. Claims submitted for renderingproviders not recognized by MagellanComplete Care will result in pended ordenied claims. Please submitMCCFLPROVIDERROSTER@magellanhealth.com21 Participating providers and facilitieshave 180 days from the date ofservice or discharge the followingtime frames to submit a clean claim toMagellan Complete Care for payment. Claims questions: call 1‐800‐327‐8613or check claims status atwww.MagellanCompleteCareofFL.com