Magellan Complete Care of Virginia

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1 Magellan Complete Care of Virginia All your questions answered and just one number to call! Call for personalized support (Mon Fri, 8 a.m. 8 p.m.) with: Orientation Care coordination Claims All your other Authorization provider service requests needs Utilization management fax: Visit our provider portal at to access: Electronic claims Electronic funds submission transfer Online training & more Active EDI clearinghouses as of 8/1/17 (Payer ID is MCCVA): Availity Trizetto Provider Office Ally Solutions Submit paper claims to: Magellan Complete Care of Virginia Claims Service Center 1 Cameron Hill Circle, Ste. 52 Chattanooga, TN Not yet in our network? Please call or VAMLTSSProvider@MagellanHealth.com for more information. We d love to have you join us! MCCofVA.com C-116 (7/17) 2017 Magellan Health, Inc.

2 Magellan Complete Care of Virginia, a CCC Plus program Nursing Facility Provider Quick Reference Joining our Network What are the benefits of being a Magellan Complete Care of Virginia network provider? As a managed care leader, Magellan Complete Care of Virginia values our network providers and realizes that your time is best spent with members not with an excess of administrative tasks. We offer many solutions to save you valuable time and resources, including: Innovative provider service Access to free online provider resources Easy claim submission and prompt payment Simplified credentialing Getting Started To be an in-network provider, the individual provider/group practice/organization must be contracted with Magellan Complete Care of Virginia. Prior to contract execution, Magellan Complete Care of Virginia ensures practitioners and organizations meet credentialing criteria and are approved by Magellan Complete Care of Virginia s RNCC (Regional Network and Credentialing Committee). To join our network us at VAMLTSSProvider@magellanhealth.com or call our Network team at Credentialing Credentialing is the process of reviewing, verifying, and periodically re-verifying practitioner and/or organization credentials in accordance with defined criteria. Credentialing is typically completed within 60days of receipt of a complete application. Provider Welcome Packets Provider welcome packets are sent once credentialing has been initiated and your contract has been executed by MCC of VA and your nursing facility. If you have applied to become part of our network and have not yet received your welcome packet, please contact our Network team at for assistance. 1

3 Billing and Payment What is the process for service authorizations requests where required? For initial custodial care members, service notification are required to capture the member s level of care. Our Care Coordinators stay engaged for all changes in level of care by working with you throughout the member s care plan. Other care services in the nursing home such as skilled care or rehabilitation may be subject to service authorizations and can be expedited as a member s condition requires. More information about service authorizations along with a complete list of service requiring authorization can be found on our provider portal at Providers can submit authorization requests via phone by calling Notice of service authorization We will inform members and providers of all decisions in writing. Medical necessity determination letters are generated at the time the determination is made and mailed via United States Postal Service to the member and provider address provided to Magellan Complete Care of Virginia. Provider notifications may also be delivered by fax, or depending on the preferred method of receipt. What is the process for claims submission? Magellan Complete Care of Virginia follows the Virginia Department of Medical Assistance Services (DMAS) guidance regarding billing and reimbursement. Please refer to DMAS billing guidelines and SFY 2018 Price-Based Rates on the DMAS web site: We offer a provider website where you can access self-service tools at After secure login, you check authorization history, submit claims, and verify the status of a claim. Electronic and paper claims Electronic Data Interchange (EDI) claims can be submitted through a clearinghouse or via direct submit. Prior to direct submit, registration and testing EDI claim submission is required. Paper claims can be submitted to the following address: MCC Claims Service Center 1 Cameron Hill Circle, Ste. 52 Chattanooga, TN For more information, visit or call provider services at What is the claim payment timeframe? Clean claims are paid to nursing facility providers within 14 days. A clean claim is one that has no defect or impropriety (including a lack of any required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payments from being made on the claim. 2

4 How will my practice/group/organization get paid for services we provide to Magellan Complete Care of Virginia members? We encourage providers to take advantage of our online Electronic Funds Transfer (EFT) feature for claims payments directly deposited to their business bank account. After registering for EFT, we will conduct a transmission test to ensure payments are transferred properly. During this time, paper checks will be mailed via United States Postal Service. Once registered for EFT, Magellan Complete Care of Virginia will pay you via electronic funds transfer (EFT). Since payments are directly deposited to the designated bank account, EFT is quick, easy, and environmentally friendly, leaving you more time to devote to your practice. How do I sign up for EFT? Once you have completed, signed and returned the Magellan Complete Care of Virginia application and contract, we will notify you to sign up for EFT. To register, you simply complete and submit an online form at There is no charge to sign up for EFT. How should Nursing Facilities bill? MCC follows DMAS methodology and the RUG-IV 48 grouper for dates of service beginning on July 1, Claims should be billed on the UB-04 claim form or the 837-I electronic format by the provider as currently billed. The RUG code should be submitted on the claim with the 0022 revenue code for room and board. The total charges for revenue code 022 should be zero and Revenue code 0658 should continue to be reported. Example of values to be reported: The RUG code determined by the RUG-IV 48 grouper must be reported in the first three digits of the Health Insurance Prospective Payment System (HIPPS) rate code locator on the UB-04 form. The type of assessment or modifier should be reported in the last two digits of the HIPPS rate code. Under the price-based reimbursement methodology, in addition to billing the revenue codes for room and board and ancillary services each nursing facility claim must contain one revenue code 0022 for each distinct billing period of the nursing facility stay MCC requires nursing facilities to report the assessment reference date with the occurrence code 50 for each RUG code reported in the HIPPS Rate Code field on the UB-04. The date of service reported with occurrence code 50 must contain the ARD associated with the applicable OBRA assessment. An occurrence code 50 is not required with the HIPPS code reported for default RUG AAA. 3

5 How should Specialized Care Facilities bill? MCC will follow the provider preferred approach utilizing the 65x series bill type with a revenue code of 199. This combination will be unique to Specialized Care providers under CCC plus. How will MCC of VA handle Patient Pay? MCC of VA utilizes the methodologies defined by DMAS for processing claims. MCC of VA assigns patient pay collection to its Participating LTSS providers. MCC of VA will automatically reduce the patient pay amount from the final claims payment for the LTSS providers such as: nursing facilities, hospice services, providers of private duty nursing in the Technology Assisted Waiver, Adult Day Care for members in the Elderly or Disabled with Consumer Direction (EDCD) waiver and agency-directed personal or respite care for members in the EDCD waiver. Patient pay will be tracked monthly as claims are processed and will be deducted from each claim for long-term care services and supports included in the new patient pay processing on a first in (date of adjudication) first out basis until fully deducted. Providers must submit claims for all services, even if providers don t expect reimbursement for a claim due to patient pay. If patient pay is updated after claims are processed, MCC will adjust impacted claims after receipt of the discrepancy report from DMAS. Using the DMAS-225 Form The Medicaid LTC Communication Form (DMAS-225) is used by the local Department of Social Services to inform LTSS providers of Medicaid eligibility and to exchange information. MCC of VA will coordinate with the provider and office staff to ensure that a completed DMAS-225 is in the record of each Member receiving Nursing Facility or waiver services. Please refer to the September 2015 Medicaid Memo for additional information regarding the Department s process on Patient Pay. 4