WIXLIB

Prior Authorization vs. Notification(cont.) A notification is communication to the plan of member medicalservices rendered. These services may or may not requireauthorization. In reference to inpatient services, notificationalone is not sufficient to create an authorization, as clinicalinformation proving medical necessity of services would berequired. Notification information should include member name, MedicaidID number, date of admission and reason for admission.Notification should be submitted via secure email tomagnoliaauths@centene.com.Facilities can submit notification via a daily census report ofMagnolia members to magnoliaauths@centene.com ORby fax at 1-877-291-8059.18

Emergent and Weekend and HolidayAdmissions Emergency and urgent care services never require prior authorization. All hospital inpatient admissions require notification as defined above to Magnolia byclose of business on the next business day following admission. Prior Authorizationrequest should be submitted within two business days. Failure to notify may result in denial of payment. Prior Authorization is NOT required for post-stabilization services. Once themember’s emergency medical condition is stabilized, certification for hospitaladmission or authorization for follow-up care is required as stated above. Non-emergent hospital inpatient admissions always require a prior authorization.19

Review Criteria Magnolia has adopted utilization review criteria developed by McKesson InterQual products to determine DOM approved medical necessity for healthcare services. Magnolia’s Medical Director reviews all potential medical necessity denials and willmake a decision in accordance with currently accepted medical or healthcarepractices, taking into account special circumstances of each case that may requiredeviation from the norm in screening criteria. Denial notification will include thereason(s) for denial per section 17.A. of the contract. Providers may obtain the criteria used to make specific determinations by contactingthe Medical Management department at 1-866-912-6285.20

Review Criteria (cont.) Members, authorized representatives or healthcare professionals with the member’sconsent, may request an appeal with Magnolia related to a medical necessity decisionmade during the authorization or concurrent review process orally or in writing to:Magnolia Health Clinical Appeals Coordinator111 East Capitol Street, Suite 500Jackson, MS 392011-866-912-6285Fax: 1-877-851-399521

Clinical ProtocolsMagnolia affirms that utilization management decision making is based only on appropriateness ofcare and service and the existence of coverage. Magnolia does not specifically rewardpractitioners or other individuals for issuing denials of service or care. Consistent with 42 CFR438.6(h) and 422.208, delegated providers must ensure that compensation to individuals orentities that conduct utilization management activities is not structured so as to provide incentivesfor the individual or entity to deny, limit, or discontinue medically necessary services to anymember.Magnolia has adopted DOM approved utilization review criteria developed by McKessonInterQual products to determine medical necessity for healthcare services. InterQualappropriateness criteria are developed by specialists representing a national panel fromcommunity-based and academic practice. InterQual criteria cover medical and surgicaladmissions, outpatient procedures, referrals to specialists, and ancillary services. Criteria areestablished and periodically evaluated and updated with appropriate involvement from providers.InterQual is utilized as a screening guide and is not intended to be a substitute for practitionerjudgment. Magnolia’s Medical Director reviews all potential medical necessity denials and willmake a decision in accordance with currently accepted medical or healthcare practices, taking intoaccount special circumstances of each case that may require deviation from the norm in thescreening criteria.Please visit the Practice Improvement Resource Center (PIRC) atwww.magnoliahealthplan.comfor Clinical Practice Guideline and Preventative Guidelines22

Magnolia Secure Web PortalTo register for the secure web portal, please refer to www.magnoliahealthplan.com. Once logged in, please select For Medical Professionals Medicaid. Once you are on the For Providers screen, you will select Login. This screen will give the providerthe option to register.BENEFITS INCLUDE: Claim submission/corrections and status Prior Authorizations submission and status Patient Panel listing Care gap identification Member eligibility verification Updates . and more!!23

Prior AuthorizationSummary Information

Magnolia Health Plan PriorAuthorization TimeframesType of AdmissionElective/PrescheduledUrgent Admission (not OBAuthorization RequestSubmission RequirementAt least 14 days before but nolater than 5 days prior toadmissiondelivery or routine well baby newborncare)Within two (2) business daysof admissionUrgent Admission (OBSee Newborn enrollment forinstructionsdelivery or routine well baby newborncare)Emergent/Urgent/Post-No Authorization neededStabilization care less than 8 hrs thatdoes not result in inpatient stayEmergent/Urgent Care (thatresults in inpatient stay)Within two (2) business daysof admission

How and Where do I submit MagnoliaAuthorizations?1 Prior Authorizations can be completed and submitted throughour Magnolia Secure Provider Web Portal*Not signed up yet for the Magnolia Secure Provider Web Portal?Secure portal website vignettes are located on the Magnolia Health Plan website in the Providersection. Your Magnolia Provider Representative can assist you in getting signed up.2 The Prior Authorization form can be printed from the Magnoliawebsite, completed and:FAXED to 1-877-291-8059OREmailed securely to magnoliaauths@centene.com3 Prior Authorization requests can be Phoned In to1-866-912-6285.

Observation Guidelines In the event that a member’s clinical symptoms do not meet the criteria for aninpatient admission, but the physician believes that allowing the patient to leave thefacility would likely put the member at serious risk, the member may be admitted tothe facility for an observation period. An observation stay may last up to a maximum of twenty-three (23) hours. (Staysless than 8 hours of observation or greater than 23 hours are not allowed.) Providers are required to notify Magnolia’s Medical Management department of anobservation stay by the next business day after discharge. A medical necessity determination will be made within three (3) calendar days/two(2) business days of receiving all required information.27

Concurrent Review Magnolia’s Medical Management department will concurrently review thetreatment and status of all members who are inpatient through contact with thehospital’s Utilization and Discharge Planning departments and when necessary,the member’s attending physician. The individual identified on the PriorAuthorization form will be considered the appropriate point-of-contact for alldischarge planning.An inpatient stay will be reviewed as indicated by the member’s diagnosis andresponse to treatment.The review will include evaluation of the member’s current status, proposed planof care, discharge plans, and any subsequent diagnostic testing or procedures.Unlike EQ Health, which allowed 19 days for a medically necessary hospital stay,Magnolia Health will conduct concurrent reviews every 5 days.In order to decrease administrative burden for both facilities and Magnolia Health,facilities can submit a daily census report of Magnolia members by email tomagnoliaauths@centene.com or by fax to 1-877-291-8059.28

Newborn EnrollmentForm and Instructions

Maternity Observation Stays Magnolia follows the APC Methodology and Observation stays arerecognized as 8-23 hours. The APC rule states that if a patient isadmitted for less than 8 hours the stay should be billed for diagnosticservices using the appropriate revenue codes and procedure codes. Ifthe stay is greater than 8 hours and up to 23 hours the stay can beprocessed and billed as Observation and a request for authorizationshould be submitted. Imaging studies that are ordered during an Observation stay do NOTrequire Prior Authorization. If the Observation stay results in an inpatient admission and delivery,then the overall service type should be changed to c-section or vaginaldelivery.30

Newborn PA RequirementsMagnolia Health Plan requires maternal information to acknowledge maternityadmission. The Division of Medicaid Newborn Enrollment Form includes all of thenecessary information for routine deliveries and well-baby care (standard 3 day stayfor vaginal deliveries, 5 day stay for C sections).The Newborn Enrollment Form must be fully completed and submitted to the Divisionof Medicaid within 5 days of delivery. If the Newborn Enrollment Form is completedand submitted timely, Magnolia Health Plan does not require any additionalinformation for mother or newborn, unless complications develop during the stay.If complications develop with mother or baby that may necessitate additionalhospital days or a non well-baby or NICU admission, a prior authorization should besubmitted along with clinical information to support the stay within one business dayof the decision that the higher level of care is needed.31

Magnolia NICU PA andConcurrent Review Process Provider submits PA form and all supporting clinicaldocumentation within 2 business days of admission. If all necessary supporting clinical documentation issubmitted and the nurse can make a determination,notification will be sent to the provider within 1business day of receipt of PA. Magnolia requires clinical information every 5 days;however this may vary on a case by case basis33

Sterilization Procedures A consent form is required for sterilizations (tubal ligationor hysterectomy) per 42 CFR Part 441, Subpart F. Magnolia utilizes DOM’s sterilization consent form, whichmust be submitted with the claim.34

Maternity/Newborn/NICUSummary

Magnolia HealthMaternity/Newborn/NICU PA TimeframesType of ServicePrior Auth RequirementConcurrent ReviewMaternity Observation(8-23 hours)Not resulting in admissionOutpatient PA within 1 business dayof dischargeNoneUrgent Admission for RoutineDeliveries (vaginal and C-section)and well baby careNewborn enrollment form submittedto DOM within 5 daysNoneWithin 2 business of AdmissionEvery 5 days(may vary on case by case)Within 2 business days of admissionEvery 5 days(may vary on case by case)Urgent Maternity Admission(complications prior to or followingdelivery that exceeds the allowed 3days for vaginal and 5 days for CsectionUrgent Newborn Admission(sick baby stay that exceeds 3 daysfor vaginal and 5 days for C-section,acute neonatal or newborn intensivecare)

Inpatient Example - Perfect ScenarioMagnolia member gets admitted to your hospital on a Friday and remains in thehospital until the following Thursday:1) You must obtain authorization no later than close of business Tuesday.Notification can be sent in on Monday, but the completed authorization MUSTbe received by Magnolia on Tuesday. Authorization should include all clinicalinformation available to support medical necessity (i.e. History and Physical,x-ray reports, labs, doctor’s progress notes including Plan of Care)2) Magnolia will make a decision within 1 business day of the completedauthorization and will provide you notification no later than 2 business days.3) If your facility will submit a daily census of Magnolia members tomagnoliaauths@centene.com or fax to 1-877-291-8059, we will be able toclose the case by seeing the discharge date on Thursday and prepare forclaims payment.

Care Management Magnolia’s Care Management program uses amultidisciplinary team approach to provide individualizedprocess for assessment, goal planning and coordination ofservices. The Care Management program is available to all members,emphasizing prevention and continuity of care. Magnolia’s Care Management team provides assistance withcomplex medical conditions, health coaching for chronicconditions, transportation assistance to appointments,interpreter services, location of community resources, andencouragement of self-management through diseaseeducation. The Care Management team will incorporate the provider’splan for the member into our Care Plan, so we can focus onthe same problems and same care interventions.38

Accessing Care ManagementAll Magnolia Health Plan members have access to Care Management services. Referrals from Providerscan be made in any of the following ways: Effective July 23, 2015, providers may log in to our Provider Portal and complete the Provider Referral Form for CareManagement and Disease Management. Go to our website www.magnoliahealthplan.com and fill out the Provider Referral Form for Care Management andDisease Management which is located under the Practice Improvement Resource Center (PIRC) section. Fax thecompleted form to 1-866-901-5813. Call Magnolia Health at 1-866-912-6285, ext. 66415 to speak with the Care Management Department. Call Magnolia Health at 1-866-912-6285 and choose the Provider prompt to speak with a Provider ServicesRepresentative who can assist you. For assistance with Prior Authorizations, call 1-866-912-6215, ext. 66408 to speak with the Prior AuthorizationDepartment. Magnolia Health Care Managers will contact the member and offer Care Management within 72 hours. Members whoagree to Care Management services will be enrolled for the time necessary to address and stabilize the condition.Providers will be asked to provide a Plan of Care so our Care Management Team can target the Care Management tothe specific needs of each member.39

Claims and Payments

Payments - APR-DRG Magnolia uses an APR-DRG payment methodology to reimburse inpatient hospitalservices. Magnolia’s goal is to promote access to care, reward efficiency, enable clarity,and minimize administrative burden for our self and our hospital partners. APR-DRGs classify each case based on information contained on the inpatient claimincluding diagnosis, procedures performed, patient age, patient sex, and dischargestatus. The APR-DRG payment is determined by multiplying the APR-DRG relativeweight by the APR-DRG base rate. Every inpatient stay is assigned a single DRG that reflects the typical resource use ofthat case. Magnolia’s DRG calculator is based off of the same parameters including base rates,outlier methods and groupers currently used by Mississippi Division of Medicaid (DOM).Magnolia will mirror APR-DRG payment under the Fee-For-Service delivery payment methodology.Version 32 of the 3M grouper and the Version 33 mapper will be used under license from 3M Health InformationSystems. Version 32 of the Health-Care Acquired Condition (HCAC) Utility and DOM APR-DRG payment parameterswill also be used by Magnolia.41

Third Party Liability Claims Third Party Liability (TPL) refers to the legal obligation of third parties (e.g., certain individuals,entities, insurers, or programs) to pay part or all of the expenditures for medical assistance furnishedunder a Medicaid state plan including Medicaid CCOs.DOM and its contracted CCOs, by law, are the “payer of last resort”; all other available third partysources must meet their legal obligation to pay claims before the Medicaid program pays for the careof an individual eligible for Medicaid.A method of avoiding payment of Medicaid claims when other insurance resources are available tothe Medicaid beneficiary is called Cost Avoidance. If a Member has resources available for paymentof expenses associated with the provision of covered services, other than those which are exemptunder Title XIX of the Social Security Act, such resources are primary to the coverage provided byDOM and must be exhausted prior to payment. In accordance with DOM’s billing manual, Magnoliawill reimburse for EPSDT, Title IV-D, and pregnancy-related services prior to billing of the third partysource, and then pursue recovery of Medicaid payment, for practitioner services. Claims submittedfor inpatient and outpatient hospital charges for labor and delivery and postpartum must be costavoided. By law, all other hospital claims are excluded from the above exceptions. Hospital claimsmust be filed with the third party prior to billing the CCOs.The Division of Medicaid Office of Recovery will conduct an annual audit to document Magnolia’scompliance with the law.42

Filing Claims when Magnolia isSecondary Coverage Magnolia will follow FFS Medicaid methodology. Providersare required to submit taxonomy numbers in box 3B. If the provider uses our web portal to submit claims, theycan upload the EOPs from the primary insurer. If the provider files paper claims, a copy of the EOP shouldbe included with the claim.

“3 Day” or 72 hour Rule Magnolia will mirror FFS Medicaid by following CMS “3 day Rule”,sometimes referred to as 72 hour rule regarding ER services,outpatient, and observation days prior to an admission. Date of Admission will be the date the patient is converted to inpatientstatus, as ordered by the physician. Magnolia will not change the date of admission to include the date thepatient entered observation status. However, the APR-DRGreimbursement includes the three days of care (if any) prior to theinpatient admission

MHAP The Mississippi Hospital Access Program, or MHAP, is a program authorizedby state legislation. The MHAP will apply to in-state hospitals and the out-ofstate hospital that is authorized by federal law to submit intergovernmentaltransfers (IGTs) to the State of Mississippi and is classified as a Level I traumacenter located in a county contiguous to the state line. It

Contract request forms can be found on Magnolia's website at www.magnoliahealthplan.com and should be completed and faxed to 866-480-3227 in order to begin the contracting process. Upon receipt of the contract request form, a Magnolia Contract Negotiator will send you a MississippiCAN