Utilization management

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.