Nebraska
Review the Magellan Appeals Process Prior to Enrollee Admission
In light of recent changes to the Nebraska Provider Handbook Supplement, we want to remind you of a few key components of the appeals process.
Admission review
It is very important that providers authorize services for Medicaid-eligible enrollees prior to the date of any admission to a behavioral health program, as specified in your handbook supplement. If a facility does not pre-authorize services on the date of admission, an admission review is required on the date of the provider’s call to a Magellan care manager. Note that the days between date of admission and the date of the call to the care manager will be technically denied, and a Reconsideration Review will not be available through Magellan. Because prior authorization is a requirement, the facility and supervising practitioner will not be reimbursed for the care provided prior to the authorization, and they cannot bill the client for the technically denied days.
Peer Review
When the care manager cannot determine that the clinical guidelines are met, or there is a question regarding the level or quality of care, the case will be referred for a Peer Review. The provider must request and schedule the Peer Review by the end of the following business day, or 24 hours.
If the peer reviewer denies the care at the Peer Review stage, the provider’s next step is a Reconsideration Review. If a client is discharged pending a Peer or Reconsideration Review, the case becomes a Retrospective Review.
Reconsideration Review
Reconsideration Review peer reviewers can uphold, reverse or modify the Peer Review denial decision. Written notification, including medical rationale of that decision and the authorization or denial number, will be sent to the supervising practitioner and the provider within 24 hours of that decision.
A Reconsideration Review must be completed prior to the provider requesting an Administrative Appeal from the Nebraska Department of Health & Human Services (NHHS). The Reconsideration Review process is not available for quality issues and technical denials.
Retrospective Review
If the client discharges pending a Peer Review or Reconsideration Review, the case becomes a Retrospective Review.
See the Nebraska Provider Handbook Supplement & Appendices for a flow chart of the complete appeals process and additional detail about the steps in the process.