MagnaCare Administrative Guidelines

1 Corporate Headquarters: One Penn Plaza, Suite 5300, New York, NY 10119 | | 2019 Brighton Health Plan Solutions, LLC MagnaCare Administrative Guidelines Updated Contents Claim Reconsideration and Dispute Resolution Claims Process Credentialing Medical Management/Quality Assurance/Utilization Review Precertification/Prior Authorization Provider Responsibilities Reimbursement State Laws Subrogation and Coordination of Benefits (COB) Transition of Care/Continuity of Care Claim Reconsideration and Dispute Resolution Claim Reconsideration and Dispute Resolution Standards ERISA appeal rights typically belong to the member and not providers unless specifically authorized by the member in accordance with the member s plan requirements. MagnaCare provider disputes regarding post-service claims will be resolved through the dispute resolution process as opposed to the member s plan s claims and appeals procedures.

evaluation and management coding guidelines • Use of other health care services consistent with the patient’s medical needs • Use of appropriate CPT codes and guidelines for visits, consultations, and treatment of the condition described • …

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