Quality management

Magellan supports the delivery of quality care with the primary goal of improving the health status of youth and families and, where the condition is not amenable to improvement, maintaining the youth’s current health status by implementing measures to prevent any further decline in condition or deterioration of health status. This includes identifying youth and families at risk of developing conditions, implementing appropriate interventions, and designating adequate resources to support the intervention(s).

Clinical/Medical Appeals

Magellan supports the right of youth and families, and their providers acting on the youth’s behalf, to appeal adverse benefit determinations.

Adverse Benefit Determination: Magellan defines an adverse benefit determination as the denial, reduction, suspension, delay, or termination of a request for admission, availability of care, continued stay, or other healthcare service upon review by Magellan of the information provided that the requested service does not meet Magellan’s requirements for medical necessity, appropriateness, healthcare setting, and/or level of care or effectiveness.

Appeal: An appeal is defined as a review by Magellan of an adverse benefit determination. Specific examples include:

• The denial or limited authorization of a requested service, including the type or level of service; requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.
• The reduction, suspension, or termination of a previously authorized service.
• The denial, in whole or in part, of payment for a service not including claims denied in whole or in part due to not meeting the definition of a “clean” claim (i.e., with no defect or impropriety). Refer to Provider Appeals (Claim Disputes) below.

Provider’s responsibility is to:

• Clinical appeals must be requested within sixty (60) calendar days from the date on the Notice of Adverse Benefit Determination (Denial) Letter.
• The provider or facility may only appeal on behalf of the youth if they have obtained the youth’s written consent (Freedom of Choice and Child, Youth, Young Adult Consent Form), which must be submitted with the appeal request.
• Request an appeal via form, telephone, fax, email or mail

Ways to request an appeal:

• Complete the Appeal Request Form
• Call us: 1-833-396-4310
• Fax: 1-888-656-5426
• Email: NevadaAppealsGrievances@MagellanHealth.com

Note: If emailing protected health information to Magellan, use secure email.

• Mail:

Connect Nevada: Strengthening Youth, Empowering Families Program
Attention: Magellan of Nevada Appeals & Grievance Department
P.O. Box 34028, Reno, NV 89533

You will also need to submit an Authorization to Use and Disclosure Protected Health Information (AUD Form) and Freedom of Choice: Child, Youth, Young Adult Consent Form.

What Magellan will do:

• Allow you, the youth, or the youth’s authorized representative to file an appeal after receiving the Notice of Adverse Benefit Determination (Denial) letter.
• We commit to resolving appeals promptly, providing written notice as quickly as the youth’s health condition requires.
• Our goal is to complete the appeal process within established timeframes, ensuring a timely response to address your healthcare needs.

Our staff appeals are handled by individuals with the necessary clinical expertise. We ensure that those involved in staff appeals have not been previously engaged in the decision-making process, especially for medical necessity appeals or those involving clinical issues.

We welcome and consider information from the youth, their representative, facility, and provider to support any appeal. Throughout the appeal process, we grant the youth and their family access to examine their case file, including medical records and other relevant documents.

We do not take punitive action against a provider for either requesting or supporting an appeal. Our commitment is to foster an environment where providers feel supported in engaging with the appeals process.

Find information about appeal procedures in Section 4 of the Provider Handbook Supplement for Connect Nevada: Strengthening Youth, Empowering Families.

Provider Appeals (Claim Disputes)

Provider’s Responsibility is to:

As a provider, you are responsible for filing a timely provider claim dispute appeal if you are not satisfied with the payment of a claim, denial of claim, recoupment of payment for a claim, or the imposition of sanctions regarding claims for services.

Magellan requires providers to submit claim dispute appeals within 60 calendar days of the date of the Explanation of Benefits. Providers can send the claim dispute appeal in one of the following ways: 

• Email: NevadaAppealsGrievances@MagellanHealth.com

Note: If emailing protected health information to Magellan, use secure email.

• Fax: 1-888-656-5426
• Mail:

Connect Nevada: Strengthening Youth, Empowering Families Program
Attention: Magellan of Nevada Appeals & Grievances Department
P.O. Box 34028
Reno, NV 89533

You will need to complete an Appeal Request Form.

What Magellan Will Do:

• Allow you to dispute a claim through a provider claim dispute appeal after receiving the Explanation of Benefits.
• Resolve and notify you in writing within 30 calendar days of receipt of your claim dispute appeal.
• Extend the timeframe for completing the review by up to 30 calendar days at the request of the youth and family, provider, or Magellan.
• Notify you of the claim dispute appeal resolution.

Find information about appeal procedures in Section 4 of the Provider Handbook Supplement for Connect Nevada: Strengthening Youth, Empowering Families.

Complaint/Grievance Process

To ensure the highest level of satisfaction and care for youth and families, Magellan is committed to establishing a mechanism for providers and external partners to voice complaints and grievances. This includes concerns related to care, service, confidentiality, policies, procedures, payments, or any other communication or action by the Connect Nevada Program.

Providers must submit complaints/grievances to Magellan in one of the following ways:

• Complete the Complaint/Grievance Form – Provider 
• Call: Magellan at 1-833-396-4310; TTY: 7-1-1; 8 a.m. to 5 p.m. PT
• Fax: 1-888-656-5426
• Email: Send a written complaint/grievance to NevadaAppealsGrievances@MagellanHealth.com

Note: If emailing protected health information to Magellan, use secure email.

• Mail: 

Connect Nevada: Strengthening Youth, Empowering Families Program
Attention: Magellan of Nevada Appeals & Grievances Department
P.O. Box 34028
Reno, NV 89533

Providers must complete the Complaint/Grievance Form – Provider, Authorization to Use and Disclosure Protected Health Information (AUD Form) and Freedom of Choice: Child, Youth, Young Adult Consent Form and submit to Magellan.

What Magellan Will Do:

• Conduct a thorough investigation for each provider complaint and grievance, adhering to statutory, regulatory, and contractual provisions. Collect relevant facts from all parties involved.
• Strive to resolve concerns at the time of the initial call; if needed, involve a supervisor or designee for issue resolution.
• Provide resolution for the complaint and grievance.
• Notify the provider regarding the disposition of the complaint and grievance.

Find information about complaints/grievances in Section 4 of the Provider Handbook Supplement for Connect Nevada: Strengthening Youth, Empowering Families.

Complaint/Grievance 3-Tier Escalation and Resolution

These steps aim to streamline issue resolution and enhance the overall provider experience if satisfaction is not achieved.

Find information about complaints/grievances in Section 4 of the Provider Handbook Supplement for Connect Nevada: Strengthening Youth, Empowering Families.

Critical Incident Reporting

Magellan requires providers to submit written notification to Magellan within 24 hours of becoming aware of the occurrence of a reportable critical incident, including the use of restraints and/or seclusions.

Magellan defines a critical incident as an unexpected occurrence involving a child, youth, young adult, providers, or contractor staff that poses an actual risk of physical or mental harm to themselves or others. This encompasses events hindering access to medical care by the provider or agency, potentially resulting in detrimental effects like death or serious disability during or after behavioral health treatment.

Critical incidents include but are not limited to:

• Homicide or attempted homicide by a child or youth served by the Connect Nevada program.
• A major injury or major trauma that has the potential to cause prolonged disability or death of a child or youth that occurs in a facility licensed by the state of Nevada to provide publicly funded behavioral health services.
• An unexpected death that occurs in a facility licensed by the state of Nevada to provide publicly funded behavioral health services.
• Abuse, neglect, or exploitation.
• Violent acts allegedly committed by a child or youth to include:
  • Arson
  • Assault resulting in serious bodily harm
  • Homicide or attempted homicide by abuse
  • Drive-by shooting
  • Extortion
  • Kidnapping
  • Rape, sexual assault, or indecent liberties
  • Robbery
  • Vehicular homicide
• Unauthorized leave of an individual with mental health challenges, particularly those with a history of offenses such as sexual or violent behavior, from a mental health facility or secure Community Transition Facility that accepts involuntary admissions. These facilities include Evaluation and Treatment Centers, Crisis Stabilization Units, Secure Detox Units, and Triage Facilities.
• Any event involving a child or youth served that has attracted or is likely to attract media attention.

Provider’s Responsibility is to:

• Complete the Critical Incident Reporting Form (includes critical incident definitions)
• Promptly notify Magellan within 24 hours of discovering a reportable critical incident involving a youth, whether it occurs at the provider’s location or elsewhere.
• Adhere to the youth’s right to be free of restraints and seclusions throughout the provision of services, explicitly prohibiting their use.
• In accordance with Nevada Revised Statutes NRS Chapter 432B, reporting is mandatory.
  • Any incidents of child or adult abuse, neglect, exploitation, and extortion must be reported to Magellan and the relevant regulatory body (e.g., State of Nevada’s Division of Child and Family Services, Child Protective Services, Aging, and Disabilities Services Division, police, etc.) as soon as possible, but no later than 24 hours.
  • For more information, visit the State of Nevada’s Division of Child and Family Services website: https://dcfs.nv.gov/
    • In Clark County, call 702-399-0081 or submit a report online: Clark County Report Form
    • In Washoe County (Reno and surrounding areas), call 833-900-7233
    • For all other counties, contact the State of Nevada’s Division of Child and Family Services at 833-571-1041, or 833-803-1183 after hours, weekends, and holidays
    • In emergencies, dial 911 to report to your local law enforcement agency

What Magellan Will Do:

• Magellan will serve as a resource to manage the clinical situation presented by the critical incident or potential critical incident and investigate incidents in a timely manner.

Find information about critical incident reporting in Section 4 of the Provider Handbook Supplement for Connect Nevada: Strengthening Youth, Empowering Families

Quality Assurance, Performance Improvement and Outcomes

Magellan is committed to continuous quality improvement through its Quality Assurance Performance Improvement (QAPI) Program, which includes assessment, planning, measurement, and re-assessment of key aspects of care and services.

In collaboration with the Division of Child & Family Services Connect Nevada Program, youths, families, providers, and stakeholders, Magellan facilitates quality activities that promote the Connect Nevada goals, sustain recovery and resiliency for youths and families, and promotes high-quality care as defined by the Institute of Medicine, which is characterized as safe, effective, member-centered, timely, efficient, and equitable care. Quality activities reinforce Magellan Health’s goals and are organized under the following three themes:

• Positively influencing the health and well-being of individuals by improving clinical outcomes, assuring youth safety, and adding value through efficiency.
• Enhancing service delivery for youth and their families.
• Ensuring that core business processes are innovative and meet or exceed contract and regulatory guidelines.

We measure and evaluate clinical care, youth safety, and preventive health services.

We pursue opportunities to improve these processes and determine to what extent interventions have had a positive effect on outcomes.

We identify opportunities for improvement through clinical review activities, including review of core performance indicators, utilization management, care management, youth and provider satisfaction, and provider site visits.

Find information about quality management in our Handbooks (Manuals) on the Resources page.

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