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Magellan Behavioral Health of Pennsylvania, Inc.
BHRS/RTF Treatment Authorization Cover Sheet
Registration ONLY
Bucks County
Date of Birth (MM/DD/YYYY):
Lehigh County
/
Montgomery County
Magellan Provider MIS #:
MA ID #:
Provider Phone:
MAGELLAN USE ONLY
Outcome
Prob
CPT
Mod1 Mod2
Code
Type
599
H0032
001
U2
HK
599
H2019
001
EP
599
H2019
001
UA
EP
599
H0032
001
HP
EP
599
H0032
001
U5
HO
599
H2021
001
EP
599
H2021
001
HQ
EP
599
H2033
001
EP
599
H2019
001
HA
599
H0046
001
U8
SC
ACT 62 Consumers – TSS SERVICES IN SCHOOL ONLY
599
H2021
001
EP
# of Units
Requested
FBA
Mobile Therapy
Mand Mtg - MT
BSC
BSC Autism Specialty
TSS
TSS Aide
MST
FFT
FFSBS
TSS ACT62
Northampton County
Provider Name:
Member Name:
Services Being Requested
MIS #
Reviewed By:
Follow-Up By:
Treatment Authorization Request
Delaware County
/
MAGELLAN USE ONLY
Start Date
(MM/DD/YYYY)
End Date
(MM/DD/YYYY)
T. Foster/Host Home
231
001
200
252
202
S5145
99221-1 unit
99231-addtl
H0019
H0019
H0019
RTF – JCAHO
151
RTF – Non JCAHO
RTF – Non JCAHO (CISC)
RTF–Group Home
BHRS After school
599
H2015
Therapeutic Summer Camp
561
H2012
Mod3
-
-
EXT:
DIAGNOSIS CODE
Approved?
Axis I:
EP
Axis II:
-
Axis III:
Axis IV:
Axis V:
DIAGNOSIS
001
001
001
001
EP
HE
HQ
EP
001
SC
EP
001
EP
By checking this box the provider attests that current POMS information has been submitted online. POMS data MUST be updated at least annually.
MAGELLAN
USE
ONLY
Date of Eval:
Date of ITM:
/
/
/
/
Date Info Due:
Date Info Received:
/
/
/
/
Date Info Requested:
/
/
Date Info Accepted:
/
/
Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) is a subsidiary of Magellan Health Services, Inc.
©2004-2011 Magellan Health Services. This document is the proprietary information of Magellan.
Select One: (“X”)
Initial
Reauthorization
Rev 01/26/2011
Date
Revised BHRS TAR Instructions
Effective February 1, 2011
Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) has reviewed the requirements for ACT 62 referrals and feedback from providers involved with the new regulations.
Magellan has found that we are now in a position to move to a streamlined approach for the authorization process for these individuals. On February 1, 2011, Magellan put into effect
the following procedures for managing Pennsylvania HealthChoices members with the Act 62 benefit.
ACT 62 Members – Services Authorized by Commercial Plan
• Commercial plan is responsible for primary coverage and authorization.
• Providers DO NOT submit any material to Magellan (Pennsylvania HealthChoices) when the primary payor is a commercial plan, except in two situations below:
Exception #1: TSS Hours in the Setting of School – Place of Service 03
• Commercial plans are not covering services provided in the school setting at this time.
o Please use the identified portion for ACT 62 TSS Services for requesting TSS in a school setting (Example 1 below).
o Magellan (Pennsylvania HealthChoices) will review the packet and make a medical necessity determination for the school hours.
o The Magellan (Pennsylvania HealthChoices) timeframe will be used for authorization periods up to one year.
EXAMPLE 1 - TSS Line for requesting School Hours ONLY
Services Being
Requested
TSS ACT62
MAGELLAN USE ONLY
Outcome
CPT
Prob Mod Mod Mod Appr(MM/DD/YYYY)
(MM/DD/YYYY)
Code
Type 1
2
3
oved?
ACT 62 Consumers – TSS SERVICES IN SCHOOL ONLY
599
H2021 001 EP
# of Units
Requested
Start Date
End Date
Exception #2: ACT 62 Members – Services Partially Authorized by Commercial Plan
• In the situation where the provider receives a partial medical necessity denial by the health plan, the provider is expected to grieve the medical necessity denial. Upon
exhausting the grievance process, the provider may submit the authorization request to Magellan (Pennsylvania HealthChoices) for medical necessity consideration.
Preauthorization and retrospective procedures apply.
Co-Payments and Deductibles
o Magellan (Pennsylvania HealthChoices) will pay the member’s portion of the co-payments and deductibles without authorization.
o Providers should submit a claim using the contract procedure code and modifiers for Magellan (Pennsylvania HealthChoices) and include a copy of the commercial
plan EOP.
Denial of Payment by Commercial Plan When an Authorization Had Been Given
• Provider is expected to appeal the denied claim for the service that had been originally authorized.
• If the provider receives written communication stating that the member does not have Act 62 coverage, Magellan (Pennsylvania HealthChoices) will review denials by the
commercial plan as described by the Medicaid Retrospective Review of Treatment Services policy.
Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) is a subsidiary of Magellan Health Services, Inc.
©2004-2011 Magellan Health Services. This document is the proprietary information of Magellan.
Rev 01/26/2011