Magellan of Virginia’s Quality Improvement Department (QI Department) promotes CQI with activities such as:
- grievance review and resolution
- quality of care and adverse outcome reviews
- reconsiderations and appeals
- treatment record reviews
- provider education, outreach and site visits
If you have questions, or would like more information about any of the topics covered here, please use the Contact Us form to submit those to the QI Department.
A grievance is a complaint by a provider, member or a member’s authorized representative; expressing dissatisfaction with the services or care a member or provider has received with Magellan or a provider/facility. Grievances will be resolved within 30 calendar days from Magellan’s date of receipt with the exception of clinically urgent Grievances (Expedited). Expedited grievances are resolved within two business days.
A reconsideration is a request from a member or provider for Magellan to review a clinical, administrative or claim denial. A reconsideration does not affect or delay the member’s right to request an appeal directly with DMAS. The reconsideration process is a prerequisite for a provider appeal to DMAS.
An appeal is a request from a member or provider for DMAS to review an adverse decision made by the Department (DMAS) or its contractors. The Appeals Division provides a process by which clients and providers can appeal adverse decisions. The basic function of the appeals process is to give clients and providers an opportunity to have another review after an adverse action has been taken. The Appeals Division has separate units that handle client appeals and provider appeals. Client appeal decisions and provider appeal decisions can be appealed to court for review of the record.
Information regarding Client and Provider Appeals can be located on the DMAS of Virginia Home, Client Services, Appeals Information.
Quality of Care Concerns
Magellan of Virginia shares the same goal as our providers, that members receive the highest quality of service. Anyone can report an issue (members, family members, providers, Magellan staff or any concerned citizen) they believe to be a potential Quality of Care Concern related to the care of members. Examples of possible Quality of Care Concerns may include the following:
- Treatment seems inappropriate for the member’s age, diagnosis, etc.
- Treatment appears inconsistent with standards of good practice.
- Providers have taken actions that could be potentially harmful to the health, well-being, or recovery of the member.
Magellan defines an adverse outcome as any of the following incidents involving a Magellan member currently in treatment or a member who was discharged from treatment within 180 days prior to the occurrence of:
- Suicide or serious suicide attempt
- An incident of violence initiated by the member
- Other incidents resulting in serious harm to the member or others that includes, but is not limited to, serious complications from a psychotropic medication regimen that required medical intervention.
Effective September 1, 2016, all Magellan participating providers are required to notify Magellan of any member Adverse Outcome that comes to their attention. Below you will find several links to additional information related to Adverse Outcomes and Magellan Provider reporting requirements.
Treatment Record Reviews
Treatment Record Review (TRR) is a method used to evaluate care being provided to members and to identify opportunities for improvement that will assist providers with improving their record keeping practices and addressing the overall quality of care that members receive. Magellan reviews a sample of treatment records from randomly selected providers. The TRR also allows us to measure network provider performance against important clinical process elements of Clinical Practice Guidelines (CPGs). All TRRs include review of the diagnosis specific CPG as well as the Suicide Risk Assessment and Management CPG.
If you prefer to receive this information hard copy, please call Magellan at 1-800-424-4046.
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