Network providers must:

• Be both credentialed and contracted with Magellan.

• Become recredentialed every three years, unless otherwise required by a customer or applicable law.

• Cooperate with Magellan's Quality Improvement Program, which could include Magellan staff visiting your site to directly assess the quality of care and services our members receive.

Depending on the services needed and geographic area served, Magellan refers members to contracted and credentialed practitioners in private practice, practitioners in a group practice or provider organizations.

We expect our providers to maintain organized, well-documented member treatment records that reflect continuity of care. Providers should document all aspects of treatment in a timely manner, including face-to-face encounters, telephone contacts, clinical findings and interventions.

For quality improvement purposes, Magellan generally reviews treatment records with providers receiving a high volume of referrals from Magellan, as required by our customers, or as part of a quality review.

You can find our policies related to treatment record reviews in the Magellan National Provider Handbook (PDF), section 4.

Magellan may conduct site visits with providers to assess the quality of care and services provided, evaluate adherence to policies and procedures, and support various quality improvement activities.

They may be conducted as a part of credentialing for participation in Magellan’s network, and on other occasions as determined by quality or clinical reviews.

Site visits can include a review of:

• Appointment availability and procedures for access
• Availability of emergency and after-hours care
• Procedures to maintain confidentiality of member information
• Physical site environment
• Treatment record-keeping practices
• Documentation in member records
• Documentation of contact with PCP
• Credentials verification of licensed clinical staff, and clinical verification and other human resources procedures for direct care staff
• Quality improvement and safety management programs.

Find our policies related to site visits in the Magellan National Provider Handbook (PDF), section 4.

Magellan’s philosophy is to maintain a diverse, quality network of providers to meet the needs of our clients and members. In addition, we believe that providers should advocate on behalf of members in obtaining care and treatment for behavioral health and substance abuse disorders.

Network providers will not be terminated from Magellan networks for any of the following reasons: Advocating on behalf of a member Filing a complaint against Magellan Appealing a decision of Magellan Requesting a review of or challenging a termination decision of Magellan.

Network providers may be terminated from Magellan networks for the following reasons, including, but not limited to: Failure to submit materials for recredentialing within required timeframes Suspension, loss or other actions on licensure Quality of care concerns Failure to meet Magellan’s credentialing criteria Provider-initiated termination No current business need within the provider’s geographic area, subject to applicable state and federal law.

For more information on your and Magellan’s contract termination obligations, consult the Magellan National Provider Handbook (PDF), section 2, and your Magellan agreement.

In support of our ongoing commitment to promoting quality care for our members, we re-review our providers’ credentials on a regular basis.

We conduct individual professional provider recredentialing every three years, unless otherwise required by applicable state and federal law, a customer, and/or an accrediting entity.

Magellan participates in CAQH^® for online data collection to help providers reduce the amount of administration and paperwork involved in credentialing and recredentialing.

For more information about recredentialing, consult the Magellan National Provider Handbook (PDF), section 2, and for information on facility/organization recredentialing, consult the Organizational Provider Handbook Supplement (PDF).

In support of NCQA, federal, and CMS regulations and standards, Magellan requires participating providers to sign into our online Provider Data Change Form each calendar quarter to validate the accuracy of their practice information.

The new federal regulations align with our existing requests that you maintain and attest to your practice/organization information, including your provider roster, at least quarterly.

Federal mandate requires your attention to practice data

The Consolidated Appropriations Act of 2021 (“CAA,” which contains the “No Surprises” rules at 42 USC 300gg-115) became effective Jan. 1, 2022. The rules seek to protect members from excessive out-of-pocket costs (surprise billing), improve access to care, and help ensure that information available to members in provider directories is updated and accurate.

The legislation is designed to serve the interests of members enrolled in commercial and employer health plans, and group or individual health insurance coverage. Thus, as a Magellan in-network provider serving this substantial population, your participation in this federally mandated process is critical.

What happens next

To comply with the CAA legislation, we are required to verify and update our provider directory information for commercial and employer plan members quarterly.* What happens to your practice information, as it appears in the provider directory, during this review, will depend on how often you validate your information:

• When you validate your practice information each quarter (as required by policy for contracted providers), your information will continue to appear in the commercial and employer plan directories.

• If you do not validate your practice information by the dates required, your information will not display in our electronic or paper directories for use by commercial and employer plan members.

• If you miss validating your practice information for a given quarter and later go back to do so, your validated practice information will again appear in our provider directories within two business days of receipt of your validation.

Not updating your information will restrict the ease with which members can contact and self-refer to you, so please work with us to regularly maintain and attest to your practice/organization information.

We appreciate your compliance and collaboration on this federally mandated initiative.

More information

Find our policies related to updating practice information in the Magellan National Provider Handbook (PDF), Section 2: Updating Practice Information, and for organizational providers in the Organizational and Facility Provider Handbook Supplement, Section 2: Communication.

*If you serve in one of the public sector programs that Magellan manages, such as District of Columbia Medicaid, Louisiana Coordinated System of Care, Pennsylvania HealthChoices, Virginia Medicaid and Wyoming Care Management Entity, please note that the data validation requirements will differ. Your provider directory information for these enrollees is not impacted by this legislation. The same is true for employee assistance programs, commercial Medicare and Medicaid plans.