: Pennsylvania HealthChoices
Peer review requirements have changed (here's what you need to know)
On Jan. 1, 2021, OMHSAS implemented a new requirement for peer reviews for all members under 21 years old when a denial is being considered for any level of care.
As a result of this update, Magellan Behavioral Health of Pennsylvania (Magellan) must now request a peer review prior to issuing any denial for medical necessity criteria (MNC) for any member under age 21.
If the member is under 21, the reasonable effort to consult with the prescriber must include a request that the member, parent, or authorized representative of the member contact the prescriber to request that the prescriber contact the behavioral health managed care organization (i.e., Magellan). Additionally, Magellan must reach out to the member (if over 14) or guardian to ask for their support in having the prescriber conduct the peer review.
Magellan is in the process of sending requests for additional information to prescribers to assist in completing this task, as well as having our staff reach out to schedule the review. We are not permitted to make a decision until the peer review occurs or 14 days have passed, whichever happens first. Therefore, MNC decisions are likely to be delayed until the peer review occurs.
We understand that this new requirement impacts providers, and we will work with you to implement the new changes as seamlessly and with as minimal disruption as possible. We request that your prescribers make themselves available to avoid unnecessary delays.