For the most recent information available in Pennsylvania, go to PA Department of Health.
File a Claim
EDI Support: Contact Magellan's EDI Hotline for support and/or assistance: 1-800-450-7281 ext. 75890 or the EDI Support Mail Box: EDISupport@magellanhealth.com
Accepted Methods for Submission of Claims
- Electronic Data Interface (EDI) via Direct Submit
- "Claims Courier"-Magellan's Web-based Claims submission tool
- EDI via a Third Party Clearinghouse
- Paper Claims: CMS-1500 (Non-Facility-Based Providers) or UB-04 (Facility-Based Providers)
Direct EDI Submission
- Direct Submission is free to providers.
- Provider sends HIPAA transaction files directly to and receives responses from Magellan without a clearinghouse.
- Direct Submit supports HIPAA 837P and 837I claims submission files.
- If you are able to create an 837 file in a HIPAA compliant format, we recommend EDI Direct Submission.
- There is a simple testing process to determine if Direct Submit is right for you.
- EDI Testing Center (www.edi.magellanprovider.com):
- Self-enroll by creating a unique user ID and password
- It's a simple six-step process which includes uploading and sending test files. Users will obtain immediate feedback regarding the results of the test to ensure compliance with HIPAA rules and codes.
- You will be assigned an IT analyst to guide you through the process and address any questions.
- The process typically takes about 3 to 4 weeks to complete the process, so allow ample time to complete your independent testing.
- To submit claims on Magellan's web site: Providers can submit claims using the Claims Courier application by signing in to the Magellan Provider Website with your secure username and password. Under My Practice, go to "Submit a Claim Online".
- A Claims Courier Demo can be accessed at: www.magellanprovider.com
- Claims Courier is a free web-based data entry application. It's similar to the CMS 1500 claim form, with additional fields to make the application HIPAA-compliant.
- Magellan recommends Claims Courier for low volume claim submitters who don't want to use a clearinghouse.
- Claims Courier is an 837P compliant application. Therefore it does not support revenue codes (codes submitted on 837I files or a UB-04).
EDI via Third-Party Clearinghouse
- Through this option, providers submit an 837 file to a third party "middle-man" who in turn submits the files to Magellan.
- Typically, a fee is attached by the clearinghouse vendor.
- Although it is not preferred, providers may also submit paper claims via a CMS-1500 form (Non-Facility-Based Providers) or UB-04 form (Facility-Based Providers).
- Paper Claims must be submitted to the below addresses (claims are not accepted at the Care Management Center in Newtown):
- MBH-Bucks, PO Box 1715, Maryland Heights, MO 63043
- MBH-Cambria, PO Box 2157, Maryland Heights, MO 63043
- MBH-Delaware, PO Box 2037, Maryland Heights, MO 63043
- MBH-Lehigh, PO Box 2127, Maryland Heights, MO 63043
- MBH-Montgomery, PO Box 2277, Maryland Heights, MO 63043
- MBH-Northampton, PO Box 2065, Maryland Heights, MO 63043
- All claims for covered services provided to HealthChoices Members must be submitted to and received by Magellan as follows:
- Within sixty (60) days from date of service for most levels of care except as provided below;
- Within sixty (60) days from date of discharge for 24/hr level of care;
- Within sixty (60) days of the last day of the month or the discharge date, whichever is earlier when billing monthly for longer treatment episodes of care at a 24/hr level facility;
- Within sixty (60) days of the claim settlement for third party claims. This date is based on the date of the other carrier’s decision.
- If Magellan does not receive a claim within these timeframes, the claim will be denied.
- In accordance with applicable law, Magellan will pay clean claims within 45 days of the date of receipt. Clean claims are defined as claims that can be processed without obtaining any additional information from the provider or from a third party.
- Upon receipt of a claim, Magellan reviews the documentation and makes a payment determination. As a result of this determination, a remittance advice, known as an Explanation of Payment (EOP) is sent to you. The EOP includes details of payment or the denial. It is important that you review all EOPs promptly.
- Resubmission of Claims: Claims that must be revised and resubmitted after adjudication must be stamped "resubmission" or otherwise noted on box 22 of the CMS-1500 form.
- Resubmissions must be submitted within 60 days from the date of denial.
- Resubmitted claims should include the Date of Original Submission and Claim number if applicable.
- Resubmissions on Claims Courier (MBH Website): changes/ corrections are allowed to Place of Service, Billed Amount or Number of Units Only (all other corrections must be submitted via paper claim). This functionality is available for claims transactions with a status of Received/ Accepted.
Third-Party Liability (TPL)
Claims for services provided to HealthChoices Members who have another primary insurance carrier must be submitted to the primary insurer first in order to obtain an EOB. HealthChoices will not make payments if the full obligations of the primary insurer(s) are not met. As a Magellan provider, you are required to hold HealthChoices members harmless and cannot bill them for the difference between your contracted rate with Magellan and your standard rate. This practice is called balance billing and is not permitted.