Authorizations and claims

Medical necessity criteria

Magellan is committed to the philosophy of providing treatment at the most appropriate, least restrictive level of care necessary to provide safe and effective treatment while meeting the individual patient’s biopsychosocial needs.

Intensive Home-Based Treatment (IHBT)

Planned and Emergency Respite Care

Youth Peer Support

Find more information about medical necessity criteria in Section 3 of the Provider Handbook Supplement for Connect Nevada: Strengthening Youth, Empowering Families.

Viewing authorizations

You soon will be able to view your authorizations from the Magellan of Nevada Payer Space in Availity Essentials.

• If you’re already using Availity Essentials with another payer, you’re set to work with Magellan of Nevada on Availity Essentials.
• If you don’t already use Availity Essentials, set up your account now. (There is no cost for registration or use.) Availity has complimentary webinars and resources to help you get started with your registration. How to get started with Availity.

Clinical/medical appeals

Magellan supports the right of youth and families, and their providers acting on the youth’s behalf, to appeal adverse benefit determinations.

Adverse Benefit Determination: Magellan defines an adverse benefit determination as the denial, reduction, suspension, delay, or termination of a request for admission, availability of care, continued stay, or other healthcare service upon review by Magellan of the information provided that the requested service does not meet Magellan’s requirements for medical necessity, appropriateness, healthcare setting, and/or level of care or effectiveness.

Appeal: An appeal is defined as a review by Magellan of an adverse benefit determination. Specific examples include:

• The denial or limited authorization of a requested service, including the type or level of service; requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.
• The reduction, suspension, or termination of a previously authorized service.
• The denial, in whole or in part, of payment for a service not including claims denied in whole or in part due to not meeting the definition of a “clean” claim (i.e., with no defect or impropriety). Refer to Provider Appeals (Claim Disputes) below.

Provider’s responsibility is to:

• Clinical appeals must be requested within sixty (60) calendar days from the date on the Notice of Adverse Benefit Determination (Denial) Letter.
• The provider or facility may only appeal on behalf of the youth if they have obtained the youth’s written consent (Freedom of Choice and Child, Youth, Young Adult Consent Form), which must be submitted with the appeal request.
• Request an appeal via form, telephone, fax, email or mail

Ways to request an appeal:

• Complete the Appeal Request Form
• Call us: 1-833-396-4310
• Fax: 1-888-656-5426
• Email: NevadaAppealsGrievances@MagellanHealth.com

Note: If emailing protected health information to Magellan, use secure email.

• Mail:

Connect Nevada: Strengthening Youth, Empowering Families Program
Attention: Magellan of Nevada Appeals & Grievance Department
P.O. Box 34028, Reno, NV 89533

You will also need to submit an Authorization to Use and Disclosure Protected Health Information (AUD Form) and Freedom of Choice: Child, Youth, Young Adult Consent Form.

What Magellan will do:

• Allow you, the youth, or the youth’s authorized representative to file an appeal after receiving the Notice of Adverse Benefit Determination (Denial) letter.
• We commit to resolving appeals promptly, providing written notice as quickly as the youth’s health condition requires.
• Our goal is to complete the appeal process within established timeframes, ensuring a timely response to address your healthcare needs.

Our staff appeals are handled by individuals with the necessary clinical expertise. We ensure that those involved in staff appeals have not been previously engaged in the decision-making process, especially for medical necessity appeals or those involving clinical issues.

We welcome and consider information from the youth, their representative, facility, and provider to support any appeal. Throughout the appeal process, we grant the youth and their family access to examine their case file, including medical records and other relevant documents.

We do not take punitive action against a provider for either requesting or supporting an appeal. Our commitment is to foster an environment where providers feel supported in engaging with the appeals process.

Find information about appeal procedures in Section 4 of the Provider Handbook Supplement for Connect Nevada: Strengthening Youth, Empowering Families.

Electronic funds transfer (EFT) sign-up

With EFT, payments are securely deposited directly into your bank account. Magellan network providers must enroll in EFT. EFT is available to providers who own the Taxpayer Identification Number (TIN) linked to the submitted claim. ECHO Health processes the payment of Magellan claims.

There are two options for EFT sign-up:

View these frequently asked questions about ECHO payment options.

Using EFT

Once you begin to receive EFT payments from ECHO, you will not receive Explanation of Payment (EOP) or Explanation of Benefits (EOB) by U.S. mail. You can access and print EOP and EOB information through ECHO’s provider portal

If you have not yet registered for the ECHO Provider Payments Portal register now.

NOTE: ECHO EFT enrollment is separate from ECHO provider portal registration.

• Draft number, draft amount (supplied with your payment from ECHO) and your TIN are required for first-time registration.
• To obtain the processing result for EFT-paid claims, you can use the Inquiry page .
• If a claim is denied, no payment is due and there will be no EFT transaction. Non-payment transaction documents are also posted.

EFT/ERA assistance

Contact ECHO Health at 1-888-834-3511 or email edi@echohealthinc.com for:

• EFT/ERA enrollment questions (status of enrollment).
• EDI questions (835 clearinghouse delivery, how to access or use the provider payments portal to download 835s).
• Changes to your bank account.

Resolution process for late or missing EFT and electronic remittance advice (ERA)

Submitting claims

Magellan of Nevada is committed to reimbursing our providers promptly and accurately in accordance with our contractual agreements. We encourage providers to submit claims electronically using one of the following methods:

Claims/billing tips

Check out our helpful claims/billing tipsheet!

Telehealth

Find information about telehealth services and claims submission in Sections 3 and 5 of the Provider Handbook Supplement for Connect Nevada: Strengthening Youth, Empowering Families.

Provider appeals (claim disputes)

Provider’s responsibility is to:

As a provider, you are responsible for filing a timely provider claim dispute appeal if you are not satisfied with the payment of a claim, denial of claim, recoupment of payment for a claim, or the imposition of sanctions regarding claims for services.

Magellan requires providers to submit claim dispute appeals within 60 calendar days of the date of the Explanation of Benefits. Providers can send the claim dispute appeal in one of the following ways: 

• Online form: Submit a Claim Appeal
• Email: NevadaAppealsGrievances@MagellanHealth.com

Note: If emailing protected health information to Magellan, use secure email.

• Fax: 1-888-656-5426
• Mail:

Connect Nevada: Strengthening Youth, Empowering Families Program
Attention: Magellan of Nevada Appeals & Grievances Department
P.O. Box 34028
Reno, NV 89533

What Magellan will do:

• Allow you to dispute a claim through a provider claim dispute appeal after receiving the Explanation of Benefits.
• Resolve and notify you in writing within 30 calendar days of receipt of your claim dispute appeal.
• Extend the timeframe for completing the review by up to 30 calendar days at the request of the youth and family, provider, or Magellan.
• Notify you of the claim dispute appeal resolution.

Find information about appeal procedures in Section 4 of the Provider Handbook Supplement for Connect Nevada: Strengthening Youth, Empowering Families.

More information

Find Magellan of Nevada policies for accurate and timely claim submission in Section 5 of the Provider Handbook Supplement for Connect Nevada: Strengthening Youth, Empowering Families.