Assessment Process
Delivering quality care starts with an accurate and thorough assessment of the member’s needs. Depending on the benefit plan, this assessment may be conducted by our care management team before making a referral or by you during the member’s first visit.
An initial assessment is required for all members to assess clinical urgency and provide clinically relevant information for the medical necessity review.
To comply with this policy, your responsibility is to:
- When the member’s benefit plan does not require a referral
- Conduct a thorough assessment of the member, including but
not limited to, the following information
- Symptoms
- Event(s) precipitating the call
- Degree of impairment in functioning
- Potential for harm to self or others
- Degree of distress
- Treatment history, including medications
- Contact the intake team at the number on the member’s benefit card or online to request authorization
- Review your assessment with our care management team
- Be available within the access standards listed in the Access to Care section of the National Provider Handbook
- Not have a “waiting list” for members
Magellan's responsibility is to:
- Assist you with requests for routine outpatient services through our customer service associates or our provider Web site
- Have our care management team assist you and/or the member with requests for services other than routine outpatient services
- Conduct a brief telephonic assessment for all services other than outpatient
- Triage the member’s needs to determine clinical urgency and match with appropriate access standards (See Access to Care section in the National Provider Handbook
- Recommend the appropriate level of care and type of services needed based on the assessment
- Determine if the member has a geographic preference for the provider’s location if the member calls
- Consider other member requests for specific provider characteristics such as gender, cultural background, etc.
- Determine the medical necessity of requested services by reviewing the results of the clinical assessment with Magellan’s Medical Necessity Criteria (See Appendix C of the National Provider Handbook) or other mandated medical necessity criteria