Magellan Healthcare
Provider Focus Newsletter
News & information for Magellan network providers

region/plan-specific news : California

Confirm member eligibility within five days before service

Important reminder about the California AB1324 legislation and member eligibility

Magellan* values your services to our members.

When Magellan has authorized services, you as the provider are responsible for confirming eligibility within five days prior to the date(s) of service to ensure that the member’s health plan coverage is still in effect. An authorization from Magellan does not guarantee eligibility.

If you conducted a service that was authorized by Magellan, but then your claim denies due to member ineligibility, you may submit a written provider payment dispute.

To be reimbursed for authorized services, you must ensure all of the following criteria are met when the patient is no longer eligible:

  • An approved authorization was issued.
  • You were the authorized provider and you delivered the service.
  • You can prove that you verified member eligibility within five business days prior to the service. 
Each case will be reviewed and handled as a provider appeal, with consideration only given to:
  • The actual authorized provider AND
  • The actual services listed on the original authorization. (Additional services not included in the authorization but routinely billed by providers as supplemental or incidental do not qualify for reimbursement.) 

More information

Visit our website at www.MagellanProvider.com for information on Claims Settlement Practice and Dispute Resolution (PDF).

Questions?

Feel free to contact us at CaliforniaProvider@MagellanHealth.com or call the Provider Services Line at 1-800-788-4005.

 

*In California, Magellan does business as Human Affairs International of California, Inc. and/or Magellan Health Services of California, Inc. – Employer Services.

 

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About Provider Focus

Welcome to Provider Focus, our award-winning e-newsletter for network providers! Here you’ll find articles and information to keep you up-to-date on news and topics relevant to serving Magellan members, including a section for regional- and plan-specific news. Check back as a new issue is released each quarter.

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