Utilization management

Utilization management

List of services that require Prior Authorization
List of Prior Authorization Codes

The purpose of the Magellan of Arizona (MCC of AZ) 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 health care 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.

Prior Authorization

Prior authorization can be requested from the MCC of AZ Utilization Management Department, which is available 24 hours a  day, 7 days a week. Providers are expected to submit a pre-service authorization request prior to providing the service or care. Any services that require an authorization but was not prior authorized, will be denied for payment. Please call us at 800-424-5891 for any questions regarding prior authorization. Providers can utilize the prior authorization forms found here and fax to 888-656-7501, including all supporting documentation.

Mail:

Magellan Complete Care of Arizona

Attn: Utilization Management Department

4801 E. Washington Street

Phoenix, AZ 85034

Fax:

888-656-7501

Email:

MCCofAZUMRequests@magellanhealth.com

To access utilization management forms, visit our Provider Tools.

Utilization management team contact

Providers can call our toll-free number at 1-800-424-5891 with any utilization management questions:

  • Our MCC of AZ team members are available for incoming calls from 8 a.m. to 5 p.m. Arizona time, Monday through Friday
  • Our MCC of AZ team members can receive incoming calls regarding utilization management concerns after normal business hours
  • Our MCC of AZ team members can send communications out regarding questions during normal business hours, unless otherwise agreed upon
  • Our MCC of AZ team members are available to accept collect calls
  • Our MCC of AZ team members will identify themselves by name, title and our organization name of MCC of AZ when initiating or returning calls
  • Our MCC of AZ team members are available to callers who have questions about the utilization management processes
  • Providers can leave voice mail messages after business hours, 24 hours a day and 7 days a week
  • A utilization management dedicated fax line can be used to submit requests for medical necessity determinations 24 hours a day and 7 days a week
  • A utilization management dedicated email can be used to submit requests for medical necessity determinations 24 hours a day and 7 days a week

Member support services

Our Member Services staff is available to help our members if they have any questions about their benefits, services, procedures, including questions regarding utilization management or have a concern about MCC of AZ.

  • Member services staff are available Monday through Friday and 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.
  • Members may access Member Services by calling our toll-free number, 800-424-5891 (TTY 711).
  • Magellan Complete Care of Arizona offers no-cost interpreter services to the member. As a provider, you are required to identify the need for interpreter services for your MCC of AZ patients and offer assistance to them appropriately.

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 criteria 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. 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 a 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, Magellan Complete Care of Arizona 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:

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 the Utilization Management Department at 800-424-5891 (TTY 711). Inpatient admissions will be reviewed for medical necessity.

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.