Sometimes benefits, treatments and medicines need to be approved by MCC of AZ before you receive them. This is called prior authorization. You, your doctor, or someone you trust can ask for a prior authorization. An approval helps let us know if certain services or procedures are medically needed.
Some examples of services that need prior authorization are:
- Outpatient surgeries
- Medical supplies (i.e. wheelchairs)
- A stay in the hospital
- Pain management
If you have any questions about what needs a prior authorization, call Member Services at 800-424-5891 (TTY 711). Many services do not need to have an authorization.
We look at standards of care based on:
- Medical policies
- National clinical guidelines
- Medicaid guidelines
- Your health benefits
Magellan Complete Care of Arizona does not reward employees, consultants, or other providers to:
- Deny care or services that you need
- Support decisions that approve less than what you need
- Say you don’t have coverage
After we get your request
MCC of AZ has a review team to be sure you receive medically necessary services. Doctors and nurses are on the review team. Their job is to be sure the treatment or service you asked for is medically needed and right for you. They do this by checking your treatment plan against medically acceptable standards. The standards we use to determine what is medically necessary are not allowed to be more restrictive than those that are used by AHCCCS. Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an adverse benefit determination (decision). These decisions will be made by a qualified health care professional. If we decide that the requested service is not medically necessary, the decision will be made by a medical or behavioral health professional, who may be a doctor or other health care professional who typically provides the care you requested. You can request the specific medical standards, called clinical review criteria, used to make the decision for actions related to medical necessity.
After we get your request, we will review it under a standard or expedited (fast) review process. You or your doctor can ask for an expedited review if you believe that a delay will cause serious harm to your health. If your request for an expedited review is denied, we will tell you and your case will be handled under the standard review process.
Clinical Practice Guidelines
MCC of AZ uses nationally accepted, evidence-based criteria, developed by specialty organizations, national policy committees (clinical practice guidelines) and/or industry recognized review organizations in addition to State or Federal criteria or regulations (as appropriate), medical policy or internally developed criteria, physician and clinical judgment to evaluate the necessity of medical and behavioral health services. MCC of AZ has adopted evidence-based clinical practice guidelines or protocols for a wide variety of medical conditions and services delivered in different medical and/or behavioral health settings. MCC of AZ has adopted MCG evidenced –based clinical practice guidelines for management of medical, behavioral, home health, and nursing facility services.
Medical criteria is approved and reviewed annually by the MCC of AZ Medical Management Committee and National Policy Committee. In accordance with 42 CFR §438.236 MCC of AZ utilizes ASAM criteria for medical necessity determinations for Addiction and Recovery Services. MCC of AZ utilizes proprietary diagnostic services criteria for imaging, sleep studies, and certain pain management procedures. These criteria sets are based on sound scientific evidence for recognized settings of care and used to decide the medical necessity and clinical appropriateness of services. If state law requires additional criteria, it is adopted into policy and used.
MCC of AZ adopts practice guidelines that meet the following requirements:
- Are based on valid and reliable clinical evidence or a consensus of health care professionals and service providers in a particular field;
- Consider the needs and preferences of the members;
- Are adopted in consultation with providers; and
- Are reviewed and updated periodically, as appropriate.
MCC of AZ disseminates any revised practice guidelines to all affected providers and, upon request, to members and potential members. The practice guidelines provide a basis for consistent decisions for utilization management, member education, coverage of services, and any other areas to which the guidelines apply.