Claims Filing Procedures
To serve our clients’ unique needs, Magellan establishes customer-specific procedures and processes. This includes whether our client or Magellan processes the claims for a specific benefit plan. Our goal is to process and pay properly submitted claims in a timely manner. To help providers properly submit claims, we provide detailed and accurate claims filing information and work to keep providers updated on procedures when they change.
We are committed to processing claims within prompt payment standards established by applicable federal or state law or as required under our provider agreements. We strive to process 99 percent of all claims within thirty (30) days of receipt, or within the time period required by applicable state regulatory standards and customer contractual agreements. A claim must contain no defect or impropriety, including a lack of any required substantiating documentation, HIPAA compliant coding or other particular circumstance requiring special treatment that prevents timely payments from being made. If the claim does not contain all required information, it may be denied.
Duplicate Claims
Magellan adjudicates all eligible claims that are submitted to a paid or denied status. Should a claim be submitted that duplicates the same expense for the same member as one that has been previously paid, Magellan will deny that claim indicating that the charge for the service was previously submitted and processed. No additional payment will be made.
Duplicate submissions of previously denied claims are reconsidered to determine if the original denial reason is still applicable. If the denial is still applicable, the claim will be denied, indicating that the charge for the service was previously submitted and processed. If the original denial reason is no longer applicable, then the claim will be reconsidered for benefit payment.
Please note that if applicable state law defines “clean claim,” Magellan applies the state-mandated definition.
To comply with this policy, your responsibility is to:
- Collect applicable co-payments from members and submit a completed claim for the services you have provided
- Submit claims for non-facility based professional services on an accurately completed paper CMS-1500 claim form or electronically through Magellan’s Web-based claims submission application or a Magellan contracted clearinghouse
- Submit completed claims for professional outpatient services provided by the staff of a facility which are not part of a structured outpatient program, or when a facility per diem is exclusive of professional charges on an accurately completed electronic or paper CMS-1500 claim form
- Submit completed paper UB-04 claim forms for facility-based services and programs or electronically through a Magellan contracted clearinghouse
- Submit all claims, paper or electronic, in compliance with regulatory and/or contractually required timely filing standards
- Use only HIPAA compliant service codes (See HIPAA Standard Code Sets Section)
- Follow the detailed claim form completion standards in Appendix F of the provider handbook;
- Respond to requests for additional information or other corrective action in a timely manner;
- Contact one of Magellan’s contracted clearinghouses if you wish to enroll and submit claims electronically to Magellan; and
- Refer to the “Dos”
(PDF
82K) and “Don’ts” (PDF
78K) of claims filing in Appendix F of the provider
handbook.
Magellan's responsibility is to:
- Provide verbal notice, send an authorization letter and/or provide electronic authorization when we authorize services
- Send you or make available online an Explanation of Payment (EOP) and other notification for each claim submitted including procedures for filing an appeal
- Provide appropriate notice regarding corrective action or information required if a claim is denied
- Reopen your claim and process to final payment upon receipt of requested information
- Adjudicate claim based on information available. Requested information that is not received within 45 days, may result in a denial for insufficient information, subject to applicable state and federal law
- Regularly update the Universal Services List and HIPAA compliant billing codes on the Magellan provider website
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