Explanation of Benefits

Quality Management Department

January 26, 2016

Agenda

• Explanation of Benefits

‒Contract Requirements

‒WAA’s Role

‒Magellan’s Responsibility

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Contract Requirements

As part of Fraud, Waste, and Abuse Monitoring, Magellan is contractually required to confirm that members received services that were paid by Medicaid. Contract requirements include:

• On a monthly basis, Magellan must provide individual EOB notices to a sample group of the members who received services in a manner that complies with 42 CFR §455.20 and §433.116(e).

‒ The sample should be a minimum random sample of at least 65 members per month

o This is equivalent to 7 members per region per month.

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Contract Requirements

• The required notice must specify:

‒The service furnished;

‒The name of the provider furnishing the service;

‒The date on which the service was furnished; and

‒The amount of the payment made for the service.

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Contract Requirements

• Surveys shall be performed within forty-five (45) days after a claim has been paid. This sampling may be performed by mail, telephonically, or in person (e.g., case management on-site visits).

‒ During the LBHP contract, Magellan utilized a mail-out, mail-in methodology.

o This methodology resulted in a poor response rate (15% or less).

‒ To better support the goal of reducing FWA in the provider network:

o Magellan will utilize a telephonic or in-person (e.g., case management on-site visits) methodology.

‒ 45 days after date of payment: What does this mean?

o Surveys require a quick turnaround time to ensure that 45-day requirement is met.

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EOBs: WAAs Role

• Magellan will send an email to each WAA containing EOB Notices for randomly selected sample of members no later than the 2nd day of the month.

‒ If this falls on a weekend, Magellan will get notices to WAAs no later than the Tuesday following the weekend.

• The notices will contain dates of services for the prior month.

‒ For example, notices sent on 1/2/2016 will be for dates of services from 12/1/15-12/31/15 and dates of payment 12/1/15-12/31/15.

• Each notice can include up to 3 services.

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EOBs: WAAs Role

• The EOB notice should be reviewed in person or telephonically with the guardian/member no later than the 15th day of the month.

‒ This will ensure that the 45-day requirement is met.

‒ If the 15th of the month falls on a weekend then the notices must be reviewed by the Friday before the 15th to ensure compliance with 45-day timeframe.

• The notice will contain selections to confirm/deny receipt of each service, comment section, and signature line for the member.

‒ If a member participates in survey telephonically, please make note of this on signature line.

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EOBs: WAAs Role

• The completed notice should be placed in the record and all notices should be returned together to Magellan no later than the 16th day of the month.

‒ For example, notices sent by 1/2/2016 would need to be returned by 1/16/16.

‒ If the 16th day of the month falls on a weekend, notices should be submitted on the Monday following the weekend.

‒ The secured method of delivery should be via:

o Fax: 1-888-656-3857

o E-mail: LACSoCQI@Magellanhealth.com

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Member Participation

• In alignment with the Wraparound Principles, members have a right to have a VOICE and CHOICE.

‒ This includes refusal to participate.

‒ If a member refuses to participate, this should be noted in the comments section and member should sign or verbal participation noted.

• Members also have up to 60 days from the date of receipt of survey to provide comments or suggestions.

‒ WAAs should assist members in filing a grievance or submitting a comment to Magellan.o This can be done informally by email or formally through the

grievance process depending on the content of the comment/suggestion.

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Response Rate

• The Goal for the Response Rate is a quarterly average of 70%.

‒ This equates to approximately 5 per month or 15 per quarter.

‒ This includes members who are surveyed but refuse to participate.

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EOBs: Magellan’s Role

• If a guardian/member indicates that they did not receive a service, Magellan will submit the notice to our Cost Containment Department for recoupment and our Special Investigation Unit for potential investigation of Fraud, Waste or Abuse.

• If a guardian/member includes a comment, Magellan will log this as a grievance and acknowledge the grievance within 3 days of receipt and resolve within 30 days.

• Report non-responders to the state within 5 days of knowledge.

• Submit quarterly reports to OBH.

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Confidentiality Statement for Providers

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The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Magellan members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.

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