Working with MCC of AZ

Utilization management

The purpose of the Magellan Complete Care of Arizona (MCC of AZ)’s utilization management program is to support optimal use of healthcare services and supports for the evaluation, treatment and integration of medical, dental and behavioral health conditions. The MCC of AZ utilization management and care management teams collaborate to ensure seamless, timely and accurate care and service authorization processes.

The utilization management department performs many functions including concurrent review, prior authorization, discharge planning assistance, retrospective review and other activities. Our utilization management program has the goal of optimizing the use of healthcare resources for our members. Services provided are not less than the amount, duration and scope for the same services delivered to fee for service AHCCCS Medicaid members. Medically necessary services are no more restrictive than used in the AHCCCS defined program. MCC of AZ makes the utilization management criteria available in writing, by mail, or fax. MCC of AZ supports continuity and coordination of care for physical, dental and behavioral health providers. Our members’ health is always our number one concern.

MCC of AZ providers can call our toll-free number at 1-800-424-5891 with any utilization management questions and our on-call utilization management nurse can be reached after hours by phone at 480-209-8403.

Member Services

Our Magellan Complete Care of Arizona (MCC of AZ)’s Member Services team is available to help our members if they have any questions about their Arizona Medicaid health benefits and services.

  • MCC of AZ’s Member Services team can be reached at 1-800-424-5891 Monday through Friday from 8 a.m. to 6 p.m. local time. Members can leave a voice message during non-business hours. We suggest our members leave a voice message with their question if it can wait until the next business day.
  • MCC of AZ offers no-cost interpreter services to our members. As a provider, you are required to identify the need for interpreter services for your MCC of AZ patients and offer appropriate assistance to them.
Prior authorizations

Prior authorizations can be requested from the Magellan Complete Care of Arizona (MCC of AZ)’s utilization management department. Providers are expected to submit a pre-service authorization request prior to providing the service or care. Any services that require an authorization but has not received an approval will be denied for payment. Please call MCC of AZ at 1-800-424-5891 for any questions regarding prior authorization. Providers can complete the prior authorization forms found on our website and fax them to 1-888-656-7501. Please include all supporting documentation.

MCC of AZ provider can submit a prior authorization request using one of the three following methods:

By mail:

Magellan Complete Care of Arizona

Attn: Utilization Management department

4801 E Washington St, Suite 225

Phoenix, AZ 85034

By fax:

1-888-656-7501

By email:

MCCAZUMRequests@MagellanHealth.com

You can access all of the MCC of AZ utilization management forms online here.

Providers can review a list of MCC of AZ services requiring prior authorization and a complete list of MCC of AZ prior authorization codes on our MCC of AZ provider forms page.

An authorization is not a guarantee of payment. Members must be eligible at the time services are rendered. Services must be a covered health plan benefit. Services must also be medically necessary with prior authorization as per Magellan Complete Care of Arizona’s policies and procedures. It is the responsibility of the provider to check for changes in the prior authorization requirements. Please contact Magellan Complete Care of Arizona with any questions or concerns at 1-800-424-5891 Monday through Friday from 8 a.m. to 6 p.m. local time.

Medical necessity criteria

Information sources used to determine benefit coverage and medical necessity include AHCCCS state coverage policies (AMPM/ACOM), MCG, Magellan Proprietary Guidelines, National Practice Guidelines/evidence-based guidelines, expert board-certified consultant advisors, enrollee-specific information gathered during care management, including behavioral and physical health history, social needs, information from family members, as well as specific treatment information from providers. The criterion used is designed to assist clinicians and providers in recognizing the most effective health care practices used today which ensures quality of care to our members. This criterion is not intended to serve as a set of rules or as a replacement for a physician’s medical judgment about their patient’s health care needs. Magellan Complete Care of Arizona (MCC of AZ) utilizes nationally established and recognized criteria, MCG, to determine medical necessity and appropriateness of care. The criterion used is designed to assist clinicians and providers in recognizing the most effective health care practices used today which ensures quality of care to our members. Criteria are reviewed at least annually with input from network providers and updated as necessary.

Utilization review determinations are based only on appropriateness of care, service, and benefit coverage. MCC of AZ does not reward providers or any staff members for adverse decisions for coverage or services. There are no financial incentives for our staff members that encourage them to make decisions that result in under-utilization. An authorization does not replace the provider’s judgment with respect to the member’s condition or treatment requirements.

If a member’s clinical documentation does not meet the criteria, the case is forwarded to an MCC of AZ Medical Director for further review and determination. The Medical Directors are available to discuss individual cases with attending physicians upon request.

Upon request, MCC of AZ will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling 1-800-424-5891 or faxing the utilization management department at 1-888-656-7501. If you would like to discuss an adverse decision with the MCC of AZ medical director, please call the utilization management department within five (5) business days of the determination.

Authorizations are not a guarantee of payment, but are based on medical necessity review, appropriate coding and benefits. Benefits may be subject to qualifications and/or limitation and will be determined when the claim is received for processing. Payment is contingent upon the eligibility of the member at the time of service.

Please note that a member ID card is not a guarantee of payment for services rendered. The provider’s office is responsible for verifying eligibility at the time of each office visit. The provider can access the following methods to verify eligibility:

By phone:

1-800-424-5891

Online:

www.MCCofAZ.com

Post-stabilization services

Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting. To request authorization for an inpatient admission or have any questions related to post-stabilization services, please contact MCC of AZ’s utilization management department at 1-800-424-5891. Inpatient admissions will be reviewed for medical necessity.

Advance directives

The member’s right to decide

Every competent adult has the right to make decisions concerning his or her own health, including the right to choose or refuse medical treatment. When a person becomes unable to make decisions due to a physical or mental change, such as being in a coma or developing dementia (such as Alzheimer’s disease), they are considered incapacitated.

To make sure that an incapacitated person’s decisions about healthcare will still be respected, the state of Arizona enacted legislation pertaining to healthcare advance directives. The law recognizes the right of a competent adult to make an advance directive instructing his or her physician to provide, withhold, or withdraw life-prolonging procedures; to designate another individual to make treatment decisions if the person becomes unable to make his or her own decisions; and/or to indicate the desire to make an anatomical donation after death.

What is an advance directive?

It is an oral or written statement about how an individual wants medical decisions to be made should they not be able to make the decisions themselves and/or it can express the wish to make an anatomical donation after death. Some people create advance directives when they are diagnosed with a life-threatening illness. Others put their wishes into writing while they are healthy, often as part of their estate planning. Three types of advance directives are:

  • A living will
  • A healthcare surrogate designation
  • An anatomical donation

A person may wish to complete any one or a combination of the three types of advance directives, depending on their needs.

What is a living will?

It is an oral or written statement about the kind of medical care a person wants or does not want if they become unable to make their own decisions. It is called a living will because it takes effect while they are still living. Many individuals discuss this with their healthcare provider or attorney to be certain they have completed the living will in a way that their wishes will be understood.

What is a healthcare surrogate designation?

It is a document in which a person names someone else to make medical decisions for them if they are unable to do so. It can include instructions about any treatment a person does or does not want, similar to a living will. It may also designate an alternate surrogate.

What is an anatomical donation?

It is a document that indicates a person’s wish to donate, at death, all or part of their body. This can be an organ and tissue donation to persons in need, or the donation of their body for the training of healthcare workers. A person can indicate their choice to be an organ donor by designating it on their driver’s license or state identification card, signing a uniform donor form, or expressing their wish in a living will.

Are individuals required to have an advance directive under state law?

No, there is no legal requirement to complete an advance directive. However, without one, decisions about a person’s healthcare or an anatomical donation may be made by a court-appointed guardian, a spouse, an adult child, a parent, an adult sibling, an adult relative, or a close friend. The person making decisions may or may not be aware of a person’s wishes. An advance directive better assures that a person’s wishes will be carried out.

Does an attorney need to prepare the advance directive?

No, the procedures are simple and do not require an attorney, although some people choose to consult one. However, an advance directive, whether it is a written document or an oral statement, needs to be witnessed by two people. At least one of the witnesses cannot be a spouse or a blood relative.

Can a person change their mind about an advance directive after they’ve completed it?

Yes, an advance directive can be changed at any time. Any changes should be written, signed and dated. However, it can also be changed with an oral statement, physical destruction of the advance directive, or by writing a new advance directive. If a person’s driver’s license or state identification card indicates they are an organ donor but they no longer want this designation, they can contact the nearest driver’s license office to cancel the donor designation and a new license or card will be issued.

What if someone filled out an advance directive in another state and needs care in Arizona?

An advance directive completed in another state, as described in that state’s law, can be honored in Arizona.

What should someone do with their advance directive if they choose to have one?

If a person wants to designate a healthcare surrogate and an alternate surrogate, they must be sure to ask them if they agree to take on this responsibility, discuss with them how matters should be handled and provide them with a copy of the document.

Make sure that their healthcare provider, attorney and the significant persons in their life know that they have an advance directive and tell them where it is located or provide them with a copy.

Set up a file where a copy of the advance directive (and other important paperwork) can be kept. Some people keep original papers in a bank safety deposit box.

Keep a card or note in their purse or wallet that states they have an advance directive and where it is located.

If an individual changes their advance directive, they should be sure that their healthcare provider, attorney and other significant persons in their life have the latest copy.

Before making a decision about advance directives, a person might want to consider additional options and other sources of information, including the following:

  • Designating a durable power of attorney, through a written document naming another person to act on their behalf. It is similar to a healthcare surrogate, but the person can be designated to perform a variety of activities (e.g., financial, legal, medical, etc.). An attorney can provide further information.

You can visit the following websites for more information regarding advance directives:

Claims submission information

As a participating provider with Magellan Complete Care of Arizona (MCC of AZ), providers have established a contractual agreement to provide physical, behavioral and/or other long-term support services to our members. The arrangement is fee-for-service for the provision of covered health care services unless otherwise specified under the provider’s Participating Agreement. The rates established in the provider’s Participating Agreement is considered full payment for covered services provided. Accordingly, MCC of AZ members may not be balanced billed for any remaining amounts and/or differences between what is billed and the provider’s negotiated reimbursement rate defined in the rate exhibit of the provider’s Participating Agreement.

What is the procedure for the reimbursement of covered services?

As a participating MCC of AZ provider, each provider agrees to bill all covered services provided to MCC of AZ members on the required forms and/or electronic claims file format. All claims should be billed on a fully completed CMS 1500, UB04 and/or CMS 1450 to be considered for adjudication and/or payment. Providers may visit the Centers for Medicare and Medicaid Services (CMS) to obtain more information about these forms and/or for more instruction and/or information on the proper use of claims forms for services.

Any claims requiring authorization should include the medical authorization number in the appropriate field of the CMS 1500, UB04 or CMS 1450 to assist with appropriate claims processing and timely claims payment. For a list of services requiring prior authorization, please visit our provider tools and resources on www.MCCofAZ.com, or as indicated, please reference Section 9: Medical Management of the MCC of AZ provider manual.

Is there a process for escalating any unresolved claims issues?

Should you need to escalate any unresolved claims issues, or if you are not satisfied with the initial claims review, please fill out the claims resolution form and email it to MCCAZProvider@MagellanHealth.com.

What is the process for submitting paper claims and medical records?

MCC of AZ participating providers are strongly encouraged to submit their claims electronically. However, paper claims can be accepted. When paper claims are submitted, they must be on properly completed original red UB04, CMS-1450 or CMS-1500 (02-12) claim form and laser-printed or typed. Please mail paper claims to:

Magellan Complete Care of Arizona

Claims Service Center

P.O. Box 1105

Elk Grove, IL 60009-1105

Medical record requests can be mailed to:

Magellan Complete Care of Arizona

Attn: Medical Records Review

4801 E Washington St, Suite 225

Phoenix, AZ 85034

Can MCC of AZ accept provider claims electronically?

MCC of AZ has the ability to accept provider claims electronically. Providers submit their claims electronically to experience the cost-saving benefits, administrative simplification as well as ease of submission and claims payment. MCC of AZ works with many claim clearinghouses. To check if MCC of AZ has a relationship with a provider’s clearinghouse, the provider may call MCC of AZ at 1-800-424-5891.

MCC01 will be our Payer ID for Change Health, Ability and WCEDI.

You can find more electronic funds transfer (EFT) information on the Change Healthcare website.

What is MCC of AZ’s timely filing procedure?

Claims for services provided to MCC of AZ members should be submitted within six months (180 days) of the date of service unless otherwise agreed upon in the Participating Provider Agreement. If not otherwise defined in the Participating Agreement and/or in the case of a non-participating provider who provides covered services to an MCC of AZ member, claims must be received within 12 months (365 calendar days) to be considered for processing and payment.

Are there any timely filing exceptions that MCC of AZ considers?

There are three timely filing exceptions that MCC of AZ takes under consideration:

  • Coordination of benefits – When a member has a primary insurance, the primary insurance Explanation of Payment (EOP) or Medicare Summary Notice (MSN) is used to determine the timely filing deadline. For these claims, the time frame begins with the print date on the primary insurance EOP or MSN.
  • Members with Retroactive Eligibility – When a member becomes eligible for an AHCCCS Complete Care program after the date of service but their coverage is backdated to include the date of service, the time frame for timely filing begins on the date MCC of AZ receives notification from the enrollment broker of the member’s enrollment.
  • Other (Good Cause) – MCC of AZ will consider exceptions on a case by case basis for other causes of filing delays, such as incorrect information provided by official sources.

What is a clean claim?

A claim is considered clean when the service is billed on the appropriate CMS form (CMS-1500, 1450 or UB04), with current coding standards in the required form field and any required attachment or supporting documentation necessary to properly process and adjudicate the claim(s).

By definition, a “clean” claim is a claim that will not require MCC of AZ to investigate or update in order to apply proper adjudication and payment. Clean claims must contain all of the basic information necessary as follows:

  • Current industry standard data coding
  • Attachments appropriate for submission and procedural circumstance
  • Completed data elements field required for the CMS-1500, CMS- 1450 or UB04

A claim is considered “unclean” if one or more of the following conditions exist due to a good faith determination and/or dispute regarding:

  • The standards or format used in the completion or submission of the form
  • The eligibility of the person listed for coverage
  • The responsibility of another payer for all or part of the claim
  • The amount of the claim or the amount currently due under the claim
  • The benefits covered
  • The manner in which services were accessed or provided
  • The claim was submitted fraudulently

What is the correct form that should be used for submitting claims to MCC of AZ?

MCC of AZ requires claims for professional services to be submitted using the CMS-1500 form. Claims for hospital/facility services (or other ancillary services) should be submitted using the CMS-1450 or UB04.

What provider-specific billing instructions and manuals does MCC of AZ follow?

MCC of AZ follows AHCCCS guidance regarding billing and reimbursement. Providers can find and refer to the AHCCCS Contractor Operations Manual (ACOM) Policy 203 regarding claims processing and the AHCCCS Fee-for-Service Provider Billing Manual Chapter 4 regarding general billing rules. MCC of AZ providers can find additional billing instructions, manuals and other coding instructions are available on the AHCCCS website.

What is MCC of AZ’s policy regarding coordination of benefits?

MCC of AZ is the payer of last resort. When the member has commercial insurance coverage, providers must bill the commercial insurance first. This includes children’s early intervention services, with the exception of:

  • Services federally required to be provided at public expense, as is the case for:
    • Assessment and evaluation
    • Development or review of the Individual Family Service Plan (ISFP)
    • Targeted case management and service coordination
  • Developmental services
  • Any covered early intervention services where the family has declined access to their private health or medical insurance

Coordination of benefits is not applicable to Arizona Vaccines for Children (AVFC) claims submitted by AVFC providers. MCC of AZ will pay these claims.

What is MCC of AZ’s balance billing policy?

MCC of AZ members must not be held responsible for any charges for Arizona Medicaid covered services. This includes those circumstances where the provider fails to obtain necessary referrals, prior authorization, or fails to perform other required administrative functions.

Providers may not balance bill MCC of AZ members for coinsurance, copayments, deductibles, financial penalties, or any other amount. Refer to Section 4: Provider Roles and Responsibilities in the MCC of AZ provider manual.

For non-covered services, Participating Providers must inform an MCC of AZ member that a service is not covered by MCC of AZ prior to rendering the service.

How are provider overpayment refunds handled?

If a provider identifies that a payment by MCC of AZ results in an overpayment, it is the responsibility of the provider to reimburse MCC of AZ for the overpaid amount within the designated time frame dictated in the Participating Provider Agreement and/or overpayment notice. The provider should return the overpayment with a copy of the Remittance Advice (RA) and a cover letter explaining why the payment is being refunded.

Overpayments should be mailed to:

Magellan Complete Care of Arizona

Attn: Network department

4801 E Washington St, Suite 225

Phoenix, AZ 85034

Explanation of remittance advice

A provider remittance advice (RA) is the MCC of AZ notification to providers upon each claim payment processed during the payment cycle. A separate remit is provided for each line of business in which a provider participates. The RA informs providers of our handling of a claim payment. Providers may elect to receive a claim payment (check) through the mail or electronically.

MCC of AZ generates checks each week. Claims processed during a payment cycle will appear on the RA form as paid, denied or reversed. Adjustments to incorrectly paid claims may reduce the check amount or cause a check to not be issued.

Information contained on the RA may include, but not be limited to, the following:

  • Claims adjudicated by MCC of AZ, including claims paid, denied, reversed, adjusted or voided
  • Summary of amount processed for this payment cycle
  • An action code that describes in more detail the results of the claim determination
  • Remit date
  • Processed amount is the total amount processed for each claim represented on the remit
  • Claims disputes rights
  • Billing provider ID number
  • AHCCCS ID number
  • Check date
  • Member/patient name
  • Birthdate
  • Account number
  • Check date
  • Provider name
  • Claim status
  • Claim number
  • Service code
  • Quantity billed
  • Amount billed
  • Excluded and non-allowed amounts
  • Allowed amount
  • Amount of other payer’s payment
  • Member co-pay/deductible/coinsurance
  • Adjustment/denial code

Pursuant to the Provider Agreement and the MCC of AZ provider manual, providers are urged to carefully review the RA and compare to prior remits to ensure proper tracking and posting of adjustments as providers remain responsible for reconciling their accounts.

Providers have the ability to direct funds to a designated bank account directly through electronic funds transfer (EFT). MCC of AZ encourages providers to take advantage of EFT. Since EFT allows funds to be deposited directly into your bank account, you will receive payment sooner than waiting for a mailed check. You may enroll in EFT by submitting an EFT application form, available on our provider portal.

Providers who have questions about claims payment, information contained on the RA or about resubmitting a claim should contact MCC of AZ claims resolution services unit at 1‐800-424-5891.

Reimbursement under the Vaccines for Children (VFC) program

The national Vaccines for Children (VFC) program was established to help raise childhood immunization rates in the United States and to keep children up to age 19 in their medical home. The entitlement program is associated with each state’s Medicaid plan. Children who are eligible for the VFC program are entitled to receive pediatric vaccines that are recommended by the Advisory Committee on Immunization Practices.

MCC of AZ providers who administer childhood immunizations should be enrolled in the AVFC program, administered by the Arizona Department of Health Services, and participate in the statewide immunization registry database. For more information and to register, contact the Arizona Department of Health Services at 602-364-3676.

Does MCC of AZ have specific information regarding behavioral health service claims?

Information on submitting behavioral health service claims can be found here.

Filing an appeal or grievance with MCC of AZ

There are several ways members or their authorized representative (including a provider on behalf of a member) can file a grievance with MCC of AZ:

By phone – Call MCC of AZ at 1-800-424-5891 Monday through Friday from 8 a.m. to 6 p.m. local time.

By emailMCCAZAppealsandGrievances@MagellanHealth.com

By mail – Members or their authorized representative may submit a grievance by mail to:

Magellan Complete Care of Arizona

Attn: Appeals and Grievance department

4801 E Washington St, Suite 225

Phoenix, AZ 85034

Members or their authorized representative also have the right to file an external grievance against MCC of AZ. Grievances against MCC of AZ may be filed through the AHCCCS Medical Management Helpline at 602-417-4000 or 1-800-654-8713 outside of Maricopa County.

Grievances can also be emailed to the AHCCCS Medical Management team at MedicalManagement@azahcccs.gov.

Finally, members or their authorized representative have the option to also file an external grievance with the Department of Health and Human Services’ Office for Civil Rights if the member believes they have not been treated fairly by MCC of AZ. Complaints regarding civil rights issues may be mailed to:

Office of Civil Rights – Region III

Department of Health and Human Services

150 S Independence Mall West Suite 372

Public Ledger Building

Philadelphia, PA 19106

Phone 1-800-368-1019

Fax 1-215-861-4431

Please visit www.hhs.gov/ocr for more information.

Filing an appeal with MCC of AZ

An appeal can be filed within 60 days of the date on the Notice of Adverse Benefit Determination. Once the notice is received, there are several ways an appeal can be filed:

By phone – Call MCC of AZ at 1-800-424-5891 Monday through Friday from 8 a.m. to 6 p.m. local time.

By emailMCCAZAppealsandGrievances@MagellanHealth.com

By mail – The member or authorized representative may send a letter to:

Magellan Complete Care of Arizona

Attn: Appeals and Grievance department

4801 E Washington St, Suite 225

Phoenix, AZ 85034

If a member or their authorized representative chooses to submit a standard appeal orally, they must also submit the request in writing within 10 days of the date of the oral request. Expedited appeals filed orally do not require a written follow-up.

Standard appeal process

MCC of AZ will review all documentation received regarding the appeal and will render a determination within 30 days of the appeal request.

Members may request an extension of up to 14 days. MCC of AZ may also request an extension of up to 14 days if we require additional information to render a decision. In the event MCC of AZ requests an extension, members or their authorized representative are notified both orally and in writing. We will call you and send a written notice within two calendar days explaining the reasoning behind extending the timeframe. You have the right to file a grievance if you disagree with the extension.

If the member or their authorized representative does not agree with MCC of AZ decision regarding the appeal, they may request a State Fair Hearing.

Expedited appeal process

If the member or their authorized representative feels that they need an immediate decision, they may request an expedited appeal. Once MCC of AZ has all of the information needed, we will provide a determination within 72 hours of the request.

If MCC of AZ determines that the appeal should not be expedited, we will inform the member of the downgrade both orally and via written notice within two calendar days indicating the reason for the decision. MCC of AZ will then resolve the appeal within the standard appeal timeframes.

The member or their authorized representative may request an extension of up to 14 days. MCC of AZ may also request an extension of up to 14 days if we require additional information to render a decision. In the event MCC of AZ requests an extension, members or their authorized representative are notified both orally and in writing. We will call you and send a written notice within two calendar days explaining the reasoning behind extending the timeframe. The member or authorized representative has the right to file a grievance if they disagree with the extension.

If the member or authorized representative does not agree with MCC of AZ’s appeal determination, they may request an expedited State Fair Hearing.

State Fair Hearing request

If the member or their authorized representative do not agree with MCC of AZ’s decision regarding their appeal, they may request a State Fair Hearing in writing within 120 days from the date on the Notice of Appeal Resolution letter sent to them.

Information about how to request a State Fair Hearing is included in the Notice of Appeal Resolution letter.

To request a State Fair Hearing in writing, please send a letter to:

Magellan Complete Care of Arizona

Attn: Appeals and Grievance department

4801 E Washington St, Suite 225

Phoenix, AZ 85034

Continuation of care

A member or authorized representative may request a continuation of care within 10 calendar days of the Adverse Benefit Determination Notice or intended date of the Adverse Benefit Determination Notice. Requests for continuation are considered if the appeal involves the following:

  • Termination, suspension or reduction of a previously authorized service
  • A denial of service(s) which the provider asserts that the service(s) or treatment(s) is/are a necessary continuation or a previously authorized service
  • The services were requested by an authorized provider and at the time the appeal was filed, the original authorization had not expired

Please note that MCC of AZ may recover the cost of continued services if the final resolution of the appeal or State Fair Hearing upholds our denial.

Provider claims disputes

Providers may challenge a claim payment, denial or recoupment through the claim dispute process. Claim disputes must be filed in writing no later than 12 months from the date of eligibility posting, or within 60 days after the payment, denial or recoupment of a timely claim submission, whichever is later. Claim disputes must provide the factual and legal basis for the dispute and the relief requested.

Claim disputes may be emailed to MCCAZProviderDisputes@MagellanHealth.com or sent by mail to:

Magellan Complete Care of Arizona

Attn: Provider Claim Disputes

4801 E Washington St, Suite 225

Phoenix, AZ 85034

Unless agreed to by MCC of AZ and the provider, we will provide a written determination within 30 calendar days of the dispute receipt date.

It is important to note that correspondence received specifically indicating a request for the reconsideration or resubmission of a claim will be forwarded directly to MCC of AZ’s claims department for review and determination.

If the provider does not agree with MCC of AZ’s claim dispute determination, they may request a State Fair Hearing.

State Fair Hearing request

If a provider does not agree with MCC of AZ’s decision regarding their appeal, they may request a State Fair Hearing in writing within 30 calendar days from the date on the Notice of Decision letter sent to them. Information about how to request a State Fair Hearing is included in the Notice of Determination letter.

Reporting fraud, waste and abuse

If you have concerns about possible fraud, waste and abuse, you can report your concerns by calling the Magellan hotline to report fraud, waste and/or abuse. If you have questions about customer service issues (e.g. a claim not paid on time or the incorrect amount paid), call the Magellan Complete Care Corporate Compliance Hotline.

You can also report fraud by filling out the fraud, waste and abuse form online. Please give as much information as possible. You do not have to give your name. AHCCCS will not share your information with the provider.

Confidential hotline numbers (available 24 hours a day, 7 days a week):

Corporate Compliance Hotline1-800-915-2108

Compliance Unit EmailCompliance@MagellanHealth.com

Magellan Complete Care Special Investigation Unit1-877-269-7624

You can send an email to the Corporate Special Investigations Unit at SIU@MagellanHealth.com or call them at 1-800-755-0850.

You can also report fraud, waste or abuse concerns directly to the Arizona Health Care Cost Containment System (AHCCCS)/Office of Inspector General (OIG) at:

Office of the Inspector General

701 E Jefferson St, MD 4500

Phoenix, AZ 85034

Phone602-417-4193 (within Maricopa County)

1-888-ITS-NOT-OK (487-6686) (outside Maricopa County)

Email – AHCCCSFraud@azahcccs.gov

Website – www.azahcccs.gov/fraud/reportfraud/

Magellan is committed to doing business honestly, ethically and following all applicable laws and regulations. Magellan’s Corporate Compliance department provides guidance on code of conduct issues, corporate policy and/or laws and regulations.

Speak up for compliance

If you want to report a compliance concern or if you have any questions regarding Magellan’s compliance program, please contact Magellan’s Corporate Compliance department. There are two ways to report a concern:

  • Compliance Hotline1-800-915-2108. The hotline is available 24 hours a day, 7 days a week. Callers may choose to remain anonymous. All calls will be treated confidentially and investigated.
  • EmailCompliance@MagellanHealth.com

Healthcare fraud, waste and abuse prevention tips

You can help us stop fraud, waste or abuse by doing these things:

  • Review your paperwork from your plan, such as your Explanation of Benefits or Service Verification surveys (if received). Make sure the following information is correct:
    • Date of service
    • Type(s) of service(s) reported
    • Name of the provider billing for those services
  • Protect your insurance card and personal information at all times. Do not share it with others.
  • Count your pills when picking up a prescription.
  • Report anything that seems wrong to Magellan Complete Care of Arizona as soon as possible.

Examples of fraud, waste and abuse:

Provider fraud, waste and abuse can include any and/or all of the following:

  • Providing medical services that are not needed
  • “Up-coding” – charging for a more complex or expensive service than was given
  • Billing for services that were not provided
  • Lying about a patient’s diagnosis so they can get tests, surgeries or other procedures that aren’t needed
  • Billing for rented medical equipment after it has been returned
  • Billing twice for the same service
  • Billing for more services than can be performed in one day
  • Asking for, offering or getting money or something of value in exchange for referrals (e.g. a doctor paying a patient to refer other Medicaid members, or to get services that are not needed)

Member fraud, waste and abuse can include any and/or all of the following:

  • Using another person’s name to get Medicaid services
  • Sharing a member ID card or using another person’s member ID card
  • Visiting several doctors to get multiple prescriptions
  • Lying to a care coordinator or someone else to try and get a service you don’t need
  • Paying a doctor cash for a prescription that is not needed
  • Making false documents by changing:
    • The date of service
    • Prescriptions
    • Medical records
    • Referral forms