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How to Get ServicesHow do I get help inan emergency?HWhat if I have an emergency when I’m awayfrom home?What is an emergency?An emergency is when aperson with an averageAlways go to theknowledge of health andclosest hospital if youmedicine thinks they must have an emergency.act fast to prevent serioushealth problems.If you think you might have a serious medicalproblem or have been injured: Call 911 or go to the closest hospital. You canuse any hospital for emergency care even if youare in another city or state.You may need behavioral health services whileyou are away from home. You might be outsidethe state of Louisiana. You have a right to useany hospital or other medical place that providesemergency care. This is called “out-of-area care.”If you are thinking about hurting yourself orsomeone else, or if you have an urgent behavioralhealth emergency: Call 911 or go to the closest hospital. You canuse any hospital for emergency care even if youare in another city or state. Tell the hospital or crisis center that you area Magellan member and ask them to callMagellan at 1-800-424-4399. Contact your provider. Or, contact Magellan any time day or night at1-800-424-4399 (TTY number is 1-800-4244416). We will help you find the right care.How do I get services that are not in thebehavioral health network (out-of-networkproviders)?If you are eligible for and enrolled to receiveservices, you can always get care in an emergency.You do not need approval for this.You can contact us to get a ride in an emergency.If you need emergency care when you are out oftown: Go to the closest hospital. You can use anyhospital for emergency care even if you are inanother city or state.If you need special services not in the behavioralhealth network, Magellan will help you get theservices you need. We will work with an out-of-network providerto make sure there is no problem getting theservices you need. You will never pay extra for these approvedservices. You will have a choice of at least two providersif there is more than one provider.How do I change providers?If you are not happy with your current provider,call Magellan to talk about what to do. Be sure andcall your provider to cancel any appointments.If you say it’s okay, the provider you have beenseeing may call your new provider and shareinformation about your behavioral health care.Magellan can help guide you through this process.Call us for free at 1-800-424-4399 any time, any day. We are here to help you. 5

How to Get ServicesWhat happens if I move?What if I’m still not sure how to get services?If you move, tell yourprovider and Magellanright away. We wantto be sure you keepreceiving your servicesand medicine. Youmay need to changeto a new provider.Magellan wants to make services as easy to get aspossible. And we want families and caregivers toplay a role.Tell Magellan and yourprovider where you nowlive if you have moved.Your provider will ask you to sign a release ofinformation. This lets the new provider transferyour services. Your records may be given to the newprovider if you give a written “okay.” Magellan oryour provider can help you find a new provider.6 Please call us for help any time at 1-800-424-4399or reach our TTY number at 1-800-424-4416.We have added new things to the behavioral healthcare program. Find out more by going to“Other Parts of the New Louisiana BehavioralHealth Partnership” on page 16, or checking outour website, www.MagellanofLouisiana.com.Magellan Health Services, Inc.

Complaints and GrievancesWhat can I do if I have a complaint orgrievance about my care?You may not be happy with the care you aregetting. Try to solve problems by talking with yourprovider or Magellan first.You can make a formal complaint or file agrievance. You can do this when you are not happywith your care and you want to fix the problem.Reasons for complaints or grievances include: You are unhappy with the quality of care orservices. You are not satisfied with how quickly anappeal is handled. You believe a provider did not respect yourrights. You believe a provider or employee of aprovider has been rude. You have been abused or mistreated by staff ofa provider. You have been put in a dangerous treatmentsetting. Or it is not legal.You can tell us about a complaint or grievance bycalling us or in writing. Or use our website,www.MagellanofLouisiana.com.Sending complaints orgrievances through thewebsiteYou can also send aYou can also send incomplaint to Magellancomplaints or grievancesthrough our website.to Magellan from yourcomputer, over the Internet.1. Go to the Grievances section ofwww.MagellanofLouisiana.com.Then, click on the link labeled “Contact Us.”2. Type your message.3. Click “Submit.”There are rules about how soon Magellan must giveyou a decision about your complaint or grievance.Magellan has 30 days to respond to your complaintand 90 days to respond to your grievance.Some issues require you to file an “appeal” insteadof a grievance. This process is described in “What isan appeal?” and “How do I file an appeal?” (Thesesections are shown on the next page.)Calling to make a grievanceCall Magellan at 1-800-424-4399 orTTY 1-800-424-4416.Written complaints orgrievancesWrite to:Magellan Health ServicesP.O. Box 84380Baton Rouge, LA 70884You can send awritten complaintto Magellan.Call us for free at 1-800-424-4399 any time, any day. We are here to help you. 7

Appeal and State Fair-Hearing ProceduresWhat is an appeal?An appeal is a formal request to Magellan. It asksfor a review of a decision about your behavioralhealth services.You have the right to ask for a review of thefollowing: Denial of a service your provider asks for. Decrease in a service. End of a service. Denial of payment for a service. Failure to provide services fast enough. Failure to act within time limits to solve anappeal or complaint. Denial of a request for services outside of theprovider network. This applies when you can’tget needed services within the network.Contact Magellan: To file an appeal over the phone or in theoffice. To get help with filing a written appeal.Call Magellan at 1-800-424-4399 or TTY 1-800424-4416.To file a written appeal, mail your request andsupporting documents to:Magellan Health ServicesP.O. Box 84380Baton Rouge, LA 70884Magellan will tell you in writing that we got yourappeal.What happens after I file an appeal?How do I file an appeal?You can file an appeal bycalling us. Or you canappeal in writing. Thereare strict rules about how People on an appealssoon you must send inpanel look at yourcase information andyour appeal. You mustmake a decision.respond within 30 daysof receiving: A Notice of Action; A Notice of Decision; or A Right to Appeal.There are also rules about how soon Magellan mustrespond. You will receive a response from Magellanwithin 30 days.An “expedited” appeal is ruled on sooner than aregular appeal. This would be because of the urgentneeds of the person sending in the appeal. ContactMagellan Member Services or your provider if yourappeal should be done faster.You have the right to give proof to support yourappeal. You can give the proof to Magellan inperson or in writing. In order to get ready for yourappeal, you may look at: Your case file. Medical records. Other documents used to resolve your appeal.If you would like to review these documents,contact your provider or Magellan. Magellan willuse the proof you gave to resolve the appeal.How is my appeal resolved?Magellan will give you a decision within 30 days.There are rules about how quickly we must solvecertain types of appeals. There are rules about howsoon we must give you a decision.If the appeal is not ruled in your favor (denied),Magellan will formally tell you the reason. And wewill also tell you what you can do next. This caninclude asking for a State Fair-Hearing.You can get help with sending in an appeal.8 Magellan Health Services, Inc.

Appeal and State Fair-Hearing ProceduresWhat if I am not happy with my appealresults?You can ask for a State Fair-Hearing if you are nothappy with the results of an appeal. If your appealwas done faster (expedited), you can ask for anexpedited State Fair-Hearing.You have the right to have a person of your choice helpyou at the State Fair-Hearing.How do I ask for a State Fair-Hearing?You must ask for a State Fair-Hearing in writing.You need to do this within 30 days of getting aNotice of Appeal Resolution from Magellan. Thisincludes both standard and expedited requests for aState Fair-Hearing.Requests for State Fair-Hearings should bemailed to:Division of Administrative Law – Health andHospital SectionP.O. Box 4189Baton Rouge, LA 70821-4189What is the process for my State FairHearing?You will receive a Notice of State Fair-Hearing.You will receive this at least 10 days before yourhearing. The Notice of State Fair-Hearing is awritten letter. It will tell you: The time and place of the hearing. The reason for the hearing. The legal basis for the hearing. The specific laws related to the hearing.How is my State Fair-Hearing resolved?For standard State Fair-Hearings, you will receive awritten decision. In most cases, you will get this nolater than 90 days after youfirst filed your appeal.A determination will bemailed to you with theresults of the State FairHearing. This will give youthe final decision about yourservices.At a State FairHearing, youcan present yourinformation.For expedited (faster) State Fair-Hearings, you willreceive a written determination. You will receive this within three working daysafter receiving your case information. You will be called to tell you about thedetermination.Will my services continue during the Appealor State Fair-Hearing?You may ask for services to continue during theappeal process. You must ask within 10 days fromthe date of the notice of action or notice of appealresolution. You may also ask for them duringthe State Fair-Hearing process. To get the sameservices, you must ask in writing for your services.The result of the appeal or State Fair-Hearing maybe to end your services.You may have to pay for the services you got duringthe State Fair-Hearing process if your appeal is deniedat the State Fair-Hearing.Call us for free at 1-800-424-4399 any time, any day. We are here to help you. 9

Privacy PoliciesIs my behavioral health informationprivate?There are laws about who can see your behavioralhealth information. It may help you to share yourbehavioral health information with others. It can go to other agencies, such as schools. You may need to give a written “okay.” You can sign a release form. This form statesthat your medical records, or parts of them,may be given to someone you name on theform. For more information about the release form,contact Magellan at 1-800-424-4399 or TTY1-800-424-4416.At times, your permission is not needed to shareyour information. This could include sharinginformation with: Providers and others who provide services. Your medical primary care doctor. Some state agencies helping with yourtreatment. Your health plan.When information can’t be kept privateThere are times when we cannot keep informationprivate. It is not protected by law at these times: You commit a crime or threaten to commit acrime. We must call the police. You are going to hurt another person. We mustlet the person know so the person can protectthemselves. We must also call the police. Possible child abuse. We must report this tolocal officials. You might hurt yourself. We must try toprotect you. We may need to talk to otherpeople in your life or other service providers.We only share the information needed to keepyou safe.You can see the behavioral health information inyour medical record. You can ask to have the record changed. You can get one free copy per year of yourmedical record. Contact your provider or Magellan at 1-800424-4399 or TTY 1-800-424-4416 to get acopy of your medical record.10 Magellan Health Services, Inc.

Member Rights and ResponsibilitiesMember Bill of Rights As a member, you have certain rights andresponsibilities. These rights are the same forfederal, state and Magellan rules. Your rights areimportant. Providers must explain your rights atyour first visit. As a member, you have the right to: Be treated with respect. Be treated with respect for your privacy. Get information about treatment in a way thatis easy to understand. Help with decisions about your care. Thisincludes the right to refuse care. Be free from any form of control used in ahostile way. Get a copy of your medical records. (Federalprivacy rules may apply.) Ask for medical records to be corrected orfixed. Get information as the law requires. Title 42,CFR, Section 438.10, is the law. It describeshow members should get information. Receive health care services the law requires.Title 42, CFR, Sections 438.206 through438.210, are the laws. These laws have rulesabout:-- Making it easy to get services.-- Getting quality care.-- Getting approvals for services. A description of after-hours and emergencycoverage, and how to get these services.A description of emergency medical conditions.A description of “post-stabilization” services.The amount and type of your benefits.The process for getting services. This includesgetting approvals.How to get a ride to services.Grievance, appeal and fair hearing procedures.This includes their time frames.This is just some of the information you can getfrom Magellan. A full list is on our website atwww.MagellanofLouisiana.com. For help with thisinformation, please contact us at 1-800-424-4399or TTY 1-800-424-4416.Your responsibilities as a memberAs a member, you have the responsibility to: Know and understand your provider’sprocedures to the best of your ability. Call your provider if you have any questions. Give information needed for your care to yourproviders. Follow instructions and guidelines from yourproviders. Know the name of your provider or casemanager. Tell providers if you have to cancel a visit. Dothis before the scheduled time.Your right to informationYou have the right to getinformation at any time fromMagellan. This includes, but isnot limited to: A Member Handbookat least once a year fromMagellan. Information aboutproviders. Your rights and protections.Magellan canprovide a fullrange of planinformationto you.Call us for free at 1-800-424-4399 any time, any day. We are here to help you. 11

Member Rights and ResponsibilitiesWhat is consent to treatment?What is an advance directive?You have the right toaccept or refuse services. If you want theservices, you or yourlegal guardian mustsign a “consent toYour provider willask you to sign atreatment” form.consent form. This signed form willgive the permission. When you sign a consent form, you give theLouisiana Department of Health and Hospitalsthe permission to see your records.You have the right to make an advance directive.An advance directive is a form. You complete thisto tell providers the kind of care you want. You dothis ahead of time. Providers look at this form ifyou are too sick to decide about your care.Your provider needs your permission to give yousome services. You may need to sign a form or give a spoken“okay.” You can decide if you want the service or not. For example, your provider may want to use amedicine. Your provider will tell you about thebenefits and risks of taking the medicine. He or she will also ask you to sign a consentform. Or you may give a verbal permission if youwant to take the medicine.A medical advance directive tells the provider aperson’s wishes. It’s used if people cannot say whatthey want because of a medical problem.A mental health advance directive tells thebehavioral health provider a person’s wishes. It’sused if people can’t say what they want because of amental illness.A mental health care power of attorney is a typeof advance directive. This gives adults the right toname another adult to make treatment decisionsfor you.Tell your family and providers if you have anadvance directive. Give copies to: All providers caring for you. This includes yourprimary care doctor. People you name as a medical or mental healthcare power of attorney. Family members or trusted friends. They canhelp your providers make choices for you.Contact Magellan Member Services to ask moreabout advance directives.You may make an advance directive. But a providermay not want to comply with it “as a matter ofconscience.” Thi

Teal: PMS 320 Dark Blue: PMS 282 Managed by Magellan Health Services in Louisiana Member Handbook Call us for help at 1-800-424-4399 Visit us online at www.MagellanofLouisiana.com