MCC of VA’s Utilization Management department performs many functions including but not limited to concurrent review, prior authorization, discharge planning assistance and retrospective review. Our Utilization Management program’s goal is to optimize the use of healthcare resources for our members. Services provided are not less than the amount, duration, and scope for the same services delivered to fee-for-service Medicaid members. Medically necessary services are no more restrictive than used in the DMAS defined program. MCC of VA supports continuity and coordination of care for physical, dental, and behavioral health providers. Our members’ health is always our number one concern.
MCC of VA makes the utilization management criteria available in writing, by mail or fax:
Mail: Magellan Complete Care of Virginia
Attn: Utilization Management Department
3829 Gaskins Road
Glen Allen, VA 23233
MCC of VA providers should call our toll-free number at 1-800-424-4524 with any utilization management questions. We’re available Monday through Friday from 8 a.m. to 6 p.m. local time. Providers can leave voice mail messages after business hours. An on-call nurse is available after hours for urgent concerns.
Member support services
MCC of VA Member Services is available to help our members if they have any questions about their benefits and services.
- Member services staff are available Monday through Friday from 8 a.m. to 8 p.m. local time. Members can leave a voice message during non-business hours. We suggest our members leave a voice message with their question if it can wait until the next business day.
- MCC of VA offers free interpreter services to our members. As a provider, you are required to identify the need for interpreter services for your patients who are MCC of VA members and offer them appropriate assistance.
Prior authorization is required for some services through MCC of VA’s Utilization Management department, which is available 24 hours a day, 7 days a week. Providers are expected to submit a pre-service authorization request prior to providing the service or care. Payment will be denied for any services that require an authorization but were not prior authorized.
Please be sure to include all required supporting documentation.
Our Care Coordinators and health guides work collaboratively in coordinating care with members and their PCP to ensure that all care and services are integrated into the member’s comprehensive treatment plan. We may allow a standing authorization to be approved for members with chronic or disabling conditions. Providers should specifically request these authorizations when working with MCC of VA case and disease managers on care plans for their patients.
Decisions on routine prior authorizations will be rendered within fourteen calendar days from the date of receipt of the request. Decisions on expedited prior authorization requests will be rendered within 72 hours from the date we receive the request if we determine that the request qualifies for expedited consideration. We will notify you if the request will not be considered as an expedited request. We base our decisions for approved services on appropriateness of care and service and existence of coverage.
If members receive care from out-of-network providers without prior authorization, MCC of VA will not pay for this care. PCPs should contact us if they wish to request an exception referral for the member to see an out-of-network provider. If an out-of-network provider gives an MCC of VA member emergency care, the service will be paid.
Medical necessity criteria
MCC of VA utilizes nationally recognized criteria, MCG Guidelines, to determine medical necessity and appropriateness of care. The criteria used are designed to assist clinicians and providers in recognizing the most effective healthcare practices used today which ensure quality of care to our members. These criteria are not intended to serve as a set of rules or as a replacement for a physician’s medical judgment about their patient’s healthcare needs. MCC of VA defaults to all applicable state and federal guidelines regarding criteria for authorization of covered services. MCC of VA also has polices developed to complement nationally recognized criteria. If a member’s clinical documentation does not meet the criteria, the case is forwarded to MCC of VA’s Medical Director for further review and determination. MCC of VA’s Medical Director is available to discuss individual cases with attending physicians upon request.
Utilization review determinations are based only on appropriateness of care, service and benefit coverage. MCC of VA does not reward providers or any staff members for adverse decisions for coverage or services. There are no financial incentives for our staff members that encourage them to make decisions that result in underutilization.
Upon request, MCC of VA will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling 1-800-424-4524 or faxing the Utilization Management Department at 1-866-210-1523 for CCC Plus or 1-855-769-2116 for Medallion 4.0. If you would like to discuss an adverse decision with MCC of VA’s Medical Director, please call the Utilization Management department within five business days of the determination.
Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting. To request authorization for an inpatient admission or if you have any questions related to post-stabilization services, please contact the Utilization Management department at 1-800-424-4524.
MCC of VA delivers a fully integrated model of care specially designed for members of Virginia’s Commonwealth Coordinated Care Plus (CCC Plus) and Medallion 4.0 programs.
Our model improves the health status of Virginians by developing person-centered care coordination delivered through Integrated Health NeighborhoodSM teams that integrate community resources and non-traditional services within local health systems. We work to ensure that natural and peer supports, housing and employment are in place, in addition to traditional behavioral and medical treatment.
Our providers are the key to our success in delivering person-centered care. Together, we can leverage our strength, experience and expertise to improve outcomes for individuals in need of comprehensive care.
Integrated Health NeighborhoodsSM
Our exclusive Integrated Health Neighborhood model helps keep our members connected to their families, friends, neighbors, healthcare providers and other connections. These can include work, school, faith communities and social support groups and services.
Our care teams include individuals who live and work in the same communities as our members. They are familiar with the local resources and services that can benefit our members the most and provide our members with choices in their neighborhood and community. Community team members include Care Coordinators, health guides, recovery support navigators, community outreach specialists, employment specialists, medical directors and others.
This Integrated Health Neighborhood model drives close collaboration with community partners, enhancing our ability to provide person-centered care to our members. It naturally bridges language and cultural barriers, and efficiently facilitates access to services to support our families where they live and work.
As a participating provider with MCC of VA, you have established a contractual agreement to provide physical, behavioral and/or other long-term support services to our members. The arrangement is fee-for-service for the provision of covered healthcare services unless otherwise specified under your Participating Agreement. The rates established in your Participating Agreement are considered full payment for covered services provided. Accordingly, MCC of VA members may not be balance billed for any remaining amounts and/or difference between what is billed and your negotiated reimbursement rates defined in the rate exhibit of your Participating Provider Agreement.
Reimbursement of covered services
As a participating MCC of VA provider, you agree to bill all covered services provided to MCC of VA members on the required forms and/or electronic claims file format. All claims should be billed on a fully completed CMS 1500, UB04 and/or CMS 1450 to be considered for adjudication and/or payment. You may visit the Centers for Medicare and Medicaid Services (CMS) website at www.cms.hhs.gov to obtain more information about these forms and/or for more instruction and/or information on the proper use of claims forms for services.
Any claims requiring authorization should include the authorization number in the appropriate field of the CMS 1500, UB04 or CMS 1450 to assist with appropriate claims processing and timely claims payment. Download this list of services requiring prior authorization. A reference to the listing is also located in Section 10: Medical Management of the MCC of VA provider handbook.
How do I submit my claims to MCC of VA?
You can submit your claims to MCC of VA by paper or electronically. You are strongly encouraged to submit your claims electronically. Electronically transmitted claims result in faster claims payment turnaround times and higher acceptance rates. However, if you choose not to bill electronically, we can accept paper claims.
Submitting electronic claims
MCC of VA offers a direct submit/web-based claims option through Availity. This functionality is available via the provider portal on our website. There is no charge to participating providers for submitting claims through the Availity tools. Availity supports keyed entry of claims on the portal and supports secure transfer/upload of batch claim files from most practice management systems. You must register with Availity to use the service and add MCC of VA as one of your payers. If you are not currently registered with Availity please visit www.availity.com to get connected.
There are several other claims clearinghouses that we work with. Please call Provider Services to check if MCC of VA has a relationship with your clearinghouse. MCC of VA’s clearinghouse payer ID for both CCC Plus and Medallion 4.0 claims is MCCVA.
Submitting paper claims
Paper claims must be submitted on properly completed CMS-1500 forms printed on Flint OCR Red, J6983, (or exact match) ink. MCC of VA uses Optical Character Recognition (OCR) technology to scan paper claims. Therefore, we will not accept black and white, handwritten, photocopied claims submissions.
Mail paper claims to:
Magellan Complete Care of Virginia
Claims Service Center
1 Cameron Hill Circle, Suite 52
Chattanooga, TN 37402
Timely filing of claims
Claims for services provided to MCC of VA members should be submitting within six months (180 days) of the date of service unless otherwise agreed upon in the Participating Provider Agreement. If not otherwise defined in the Participating Agreement, and/or in the case of a non-participating provider who provides covered service to MCC of VA members, claims must be received within twelve months (365 calendar days) to be considered for processing and payment.
There are three timely filing exceptions that MCC of VA takes under consideration:
- Coordination of benefits – When an MCC of VA member has a primary insurance, the primary insurance Explanation of Payment (EOP) or Medicare Summary Notice (MSN) is used to determine the timely filing deadline. For these claims, the time frame begins with the print date on the primary insurance EOP or MSN.
- Members with retroactive eligibility – When a member becomes eligible for a DMAS Medicaid program after the date of service, but their coverage is backdated to include the date of service, the time frame for timely filing begins on the date MCC of VA receives notification from the enrollment broker of the member’s enrollment.
- Other (good cause) – MCC of VA will consider exceptions on a case by case basis for other causes of filing delays, such as incorrect information provided by official sources.
Corrected claims, adjustments, or reconsiderations should be submitted within 180 days of the original claim paid date in order to be considered for reprocessing.
Processing and payment of claims for covered services are generally made within 30 calendar days of receipt of a clean claim. For more information on claims submission and payment, please refer to the MCC of VA provider handbook.
Provider appeals are requests made by the MCC of VA providers (in-network and out-of-network) to review the MCC of VA’s adverse benefit determination in accordance with the statutes and regulations governing the Virginia Medicaid appeal process. After a provider exhausts MCC of VA’s internal appeal process, Virginia Medicaid affords the provider the right to two (2) administrative levels of appeal (informal appeal and formal appeal) in accordance with the Virginia Administrative Process Act (Code of Virginia Section 2.2-4000 et seq.) and Virginia Medicaid’s provider appeal regulations (12 VAC 30-20-500 et seq.).
Providers may submit reconsiderations to MCC of VA if a provider has rendered services to a member and has been denied authorization/reimbursement for services or has received reduced authorization/reimbursement.
A provider may file an appeal with MCC of VA within 60 calendar days from the date of the adverse benefit determination notice/remittance advice. Failure to file an appeal with MCC of VA within this time frame shall result in an administrative dismissal.
A provider must file the appeal with MCC of VA in writing, although the appeal may be started verbally. The appeal must identify the issues, adjustments, or items the provider is appealing and include any supporting documentation, which explains or satisfies the reason for the original denial and why it should be paid accordingly.
There are several ways to file an appeal:
- By phone
- Call Provider Services at 1-800-424-4524 Monday through Friday from 8 a.m. to 6 pm. local time. Providers may leave a message after hours that will be returned the next business day.
- By mail
- Send your appeal request to:
Magellan Complete Care
Attn: Appeals Specialist
3829 Gaskins Road
Richmond, VA 23233
- Send your appeal request to:
- By secure email
- By fax
For more information about provider appeals, refer to Section 9 of your provider handbook.
MCC of VA does not tolerate fraud, waste or abuse, by providers, members or staff. Accordingly, we have instituted extensive fraud, waste and abuse programs to combat these problems. MCC of VA’s programs are wide-ranging and multi-faceted, focusing on prevention, detection and investigation of all types of fraud, waste and abuse in government programs and private insurance.
MCC of VA’s expectation is that providers will fully cooperate and participate with its fraud, waste and abuse programs. This includes, but is not limited to, permitting MCC of VA access to member treatment records and allowing MCC of VA to conduct on-site audits or reviews. MCC of VA also may interview members as part of an investigation without notifying the provider.
Reporting suspected fraud, waste and abuse
MCC of Virginia expects providers and their staff and agents to report any suspected cases of fraud, waste or abuse. MCC of VA will not retaliate against a provider who informs MCC of VA, the federal government, state government or any other regulatory agency with oversight authority of any suspected cases of fraud, waste or abuse.
MCC of VA has the responsibility to assess the merits of any allegation of fraud, waste, or abuse. MCC of VA will coordinate and fully cooperate and assist DMAS and any other state or federal agency in identifying, investigating, sanctioning or prosecuting suspected fraud, abuse or waste. MCC of VA will provide records and information, as requested.
You can report suspected fraud, waste and abuse to MCC of VA by the following methods:
We accept reports to the Corporate Compliance Hotline 24 hours a day/seven days a week. The hotline is maintained by an outside vendor. Callers may choose to remain anonymous. All calls will be investigated and remain confidential.
In addition to reporting suspected fraud, waste, or abuse to MCC of VA, you can report to these other agencies:
Virginia Medicaid Fraud Control Unit (Office of the Attorney General)
Mail: Office of the Attorney General
Medicaid Fraud Control Unit
202 North Ninth Street
Richmond, VA 23219
Virginia Office of the State Inspector General Fraud, Waste, and Abuse Hotline
Mail: State FWA Hotline
101 N. 14th Street
The James Monroe Building 7th Floor
Richmond, VA 23219
You can also contact the U.S. Department of Health & Human Services Office of Inspector General at:
Office of Inspector General Department of Health & Human Services
P.O. Box 23489
Washington, DC 20026
Phone: 1-800-HHS-TIPS (TTY 1-800-377-4950)
To report suspected recipient fraud to DMAS, contact:
Department of Medical Assistance Services
Recipient Audit Unit
600 East Broad Street, Suite 1300
Richmond, VA 23219
For more information on fraud, waste and abuse, refer to Section 6 of your provider handbook.
Please use the button below to contact us with any questions or comments.
Preferred drug list
MCC of VA has a list of covered drugs that are selected by us with the help of a team of doctors and pharmacists.
This list of covered drugs also includes all the drugs on the DMAS Preferred Drug List (PDL). The list includes which drugs are covered by us and tells you if there are any rules or restrictions on any drugs, such as a limit on the amount a member can get.
MCC of VA will pay up to $50 per quarter for select over-the-counter (OTC) products for members with an active prescription from a participating provider. These products can include:
- Cough and cold medicines
- Artificial tears
- Topical antibiotics
- Gastrointestinal medicines
Please review this list to find out what drugs are covered by MCC of VA. If you would like a paper copy of the list of covered drugs, please call us at 1-800-424-4524 and we will mail a copy to you. Please be aware that this list may change throughout the year.
If you prescribe a drug that is impacted by a change to the list of covered drugs, you will be notified in writing 30 days prior to the change taking effect.
This list will tell you which drugs have recently been recalled.
MCC of VA Specialty Pharmacy Program
MCC of VA is committed to providing you and your patients with access to quality services and cost-effective prescription drugs. Magellan Rx Pharmacy, LLC through their Magellan Rx Specialty division provides specialty pharmacy services to your patients.
What this means to you and your patients
Prescription drug requests for specialty medications for MCC of VA members need to be submitted to Magellan Rx Pharmacy for fulfillment. Your patient may call Magellan Rx Specialty Pharmacy at 1-866-554-2673 to discuss opting out of this program and have his or her current specialty pharmacy continue to provide the medication.
Our current Prior Authorization (PA) process will stay the same. Patients with an existing authorization will not need to request a new PA until the current authorization has expired.
Services and programs to help patients stay on your treatment plan
With Magellan Rx, your patients have access to the following specialty services:
- Insurance specialists to help get the most out of benefits
- Coordination of medication, including delivery to your office or patient’s home
- Important supplies at no additional cost, such as syringes and needles
- Highly trained pharmacists and nurses available toll-free to answer any questions
- Online member portal to request refills and learn more
- Access to community resources
To submit a prescription, or if you have questions, please contact Magellan Rx Pharmacy at 1-866-554-2673.
J Code Prior Authorization Changes
See a list of prior authorization requirement changes effective October 1, 2020.
These medications require prior authorization effective September 1, 2020.
Please refer to the prior authorization list for a complete list of medications and services that require prior authorization.
Effective July 1 2020, MCC of VA implemented a Biosimilar Program for you and your patients that includes the JCodes listed below:
- J0885 Epoetin alfa, non-esrd
- J1442 Inj filgrastim excl biosimil
- J1745 Infliximab not biosimil 10mg
- J2505 Injection, pegfilgrastim 6mg
- J9035 Bevacizumab injection (excludes intraocular bevacizumab injections)
- J9355 Inj trastuzumab excl biosimi
- J9312 , rituximab, 10 mg
A biosimilar product is highly similar to, and has clinically meaningful differences in safety, purity and potency (safety and effectiveness) from, an existing FDA-approved reference product. A manufacturer developing a proposed biosimilar demonstrates that its product is highly similar to the reference product by extensively analyzing (i.e.,characterizing) the structure and function of both the reference product and the proposed biosimilar. A manufacturer must also demonstrate that its proposed biosimilar product has no clinically meaningful differences from the reference product in terms of safety, purity, and potency (safety and effectiveness).
JCode utilization management medical necessity requests for reference products that have a biosimilar product will require a trial/failure of the respective biosimilar product. Patients with an existing authorization or who are currently on a reference product will not be required to try/fail a biosimilar product. Additional information on biosimilars may be accessed at the U.S. Food and Drug Administration Biosimilar website.
Provider Relations Managers
How to submit provider rosters and roster updates
Please read the following rules and guidelines for submitting rosters and roster updates.
- All provider rosters submitted for processing must include a complete listing of par providers associated with:
- Participating group practices of 5 or more providers
- Hospitals and hospital systems
- PHOs, IDNs and other contractual relationships that include multiple providers (practitioners and/or facilities)
- To comply with CMS and state Medicaid regulatory requirements, providers should submit full roster updates on a quarterly basis (once every 3 months)
- Interim roster updates/changes can be submitted on a monthly basis and must contain a minimum of 5 affiliated providers.
Updates submitted for fewer than 5 providers will not be accepted. Please see the section titled How to submit provider maintenance tasks for updates to individually contracted providers and groups of fewer than 5.
- All provider rosters and provider roster updates must be submitted using the Excel spreadsheet template below and include all the required data elements.
- Any roster, roster update or provider data maintenance request that does not contain all required data elements will be returned to the contracted provider entity (submitter) to append the missing information.
- Completed requests should be saved using the following file naming conventions: [provider name_date].xls
Example file names:
Group Practice: ABCPediatrics_01012020
Health System, IPA, PHO: BaptistHealthSystem_01012020
- Email completed rosters, roster updates and provider data maintenance files/forms to MCCVAproviderroster@magellanhealth.com.
- All provider rosters, roster updates and data maintenance tasks including the required data elements will be processed within 30 calendar days from the date of receipt (via email). Upon completion, an email confirmation will be sent to the address provided on the original request.
How to submit provider maintenance tasks
Individually contracted providers (solo practitioners/facilities) and group practices with fewer than 5 providers can update their demographic information by submitting a provider maintenance task.
- Provider maintenance tasks can be submitted each month (as needed) by downloading and completing the following Excel spreadsheet template.
- Provider data maintenance tasks that do not contain all required data elements will be returned to the contracted provider entity (submitter) to append the missing information.
- Completed requests should be saved using the following file naming conventions.
Example file names:
Individual Provider: JohnSmith_01012020
Small Group Practice: ABCPediatrics_01012020
Please note groups must be less than 5 providers
- Email provider data maintenance files/forms to MCCVAProvider@magellanhealth.com.
- All provider data maintenance forms will be completed within 30 calendar days from the date of receipt (via email). Upon completion, an email confirmation will be sent to the address provided on the original request.