Provider Quality

We appreciate your commitment to serving our special needs population. To help you focus on providing the best possible care to your patients, we’ve compiled our quality materials all in one place. If you have questions or suggestions, please contact us.

Provider Relations phone: 1-800-424-4509
Provider Relations email: MCCAZProvider@magellanhealth.com 

Magellan Complete Care’s Corporate Compliance Program

MCC Corporate Compliance is a comprehensive program designed to educate all employees on the ethical standards and code of conduct that guide our operations and promotes reporting of inappropriate behavior and unlawful activity. The compliance program applies to all lines of business and includes:

  • Oversight: MCC of AZ (HMO SNP) is committed to conducting our business operations honestly and ethically, keeping with applicable federal and state statutes, ethical standards, rules and regulations. Magellan’s Special Investigations’ Unit (SIU) provides oversight of these for members, providers/suppliers, governmental agencies and First Tier, Downstream and Related Entities.
  • Alignment: We align our practices with those of the Centers for Medicare and Medicaid Services (CMS) Part C and D programs and the Arizona Health Care Cost Containment System (AHCCCS) and AHCCCS Office of the Inspector General (OIG). For a full list of the applicable regulatory compliance policies, please see pages 9–12 of the Provider Handbook.
  • Reporting: Our Fraud, Waste and Abuse (FWA) program is an integral part of our Compliance Program. For more information on how to identify and report violations, you can:

– Phone Magellan’s Special Investigations Unit (SIU) hotline at 1-800-755-0850

– Email us at SIU@MagellanHealth.com

– Contact us confidentially using Magellan’s Corporate Compliance Hotline at 1-800-915-2108

MCC of AZ (HMO SNP)’s Quality Improvement Program (QIP) 

QIP is designed to measure, assess and improve the quality of care and quality of service we provide our members. Our program includes steps to ensure member safety, manage their complex healthcare issues, and meet their diverse cultural and linguistic needs.

Quality improvement activities focus on member satisfaction, complaints and appeals, contract services and credentialing, clinical services, utilization management and clinical program initiatives, outreach activities, education and reporting compliance. We annually select specific quality improvement initiatives for implementation and evaluation at year’s end.

For more information, please contact Member Services at 1-800-424-4509 (TTY 711).

HEDIS® Measures of Focus 

Each year, performance measures are developed and maintained by the National Committee for Quality Assurance (NCQA). These performance measures are critical in the accreditation process for healthcare providers.

As an MCC of AZ (HMO SNP) provider, you play a major part in helping us achieve and report on these quality of care measures for our members—beginning with services you provide, extending to the way you code them and finishing with your support during chart reviews.

The Healthcare Effectiveness Data and Information Set (HEDIS®) allows consumers to compare health plan performance to other plans and to national or regional benchmarks. HEDIS® results are used to track year-to-year performance. The HEDIS® measures are divided into six (6) “domains of care:”

  • Effectiveness of Care
  • Access/Availability of Care
  • Experience of Care
  • Utilization and Risk Adjusted Utilization
  • Health Plan Descriptive Information
  • Measures Collected Using Electronic Clinical Data Systems

HEDIS® data is collected through surveys, medical charts and insurance claims for hospitalizations, medical office visits, procedures and pharmacy services.

There are some HEDIS® measures that are based upon administrative (claims) data. To support these measures, it is important that providers use appropriate, up-to-date diagnosis and procedure codes to assure that services are accurately captured. You can find the HEDIS® Measures of Focus Guide here; download it to learn more about the importance of participation and accurate reporting of measures achieved.

Also available is the recently published HEDIS® Telehealth Codes Reference Guide, which includes program codes for telehealth services you might provide. Click the link above to download it.

The Medicare Star Ratings Program 

This Medicare quality program rates all health and prescription drug plans each year, based on a plan’s quality and performance. Download this document to learn more about the program.