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What to expect after a review by Magellan’s Special Investigations Unit (SIU)

At the conclusion of an audit or investigation, Magellan’s SIU will send you the outcome in writing.

You will receive a letter detailing SIU's findings--some things to expect

• SIU may ask you to sign an audit findings attestation form, attesting to your receipt and understanding of any education, resources and other information that were shared with you in response to our findings.
• SIU may report findings to the health plan and/or an external oversight agency, place your claims on pre-payment review, and/or require you submit a corrective action plan (CAP). Be sure to complete and submit any requested CAP in the time specified by the investigator.
• SIU will refer overpayments found during an audit, investigation or as the result of a self-audit, to Magellan’s Cost Containment department for recovery. This is done in compliance with contractual and regulatory requirements, through your submission of a refund check, or by Magellan offsetting the amount overpaid against future payments.

You have the right to appeal SIU's findings

• Within the appeal timeframe specified in the letter:

• Be sure to respond to the auditor or investigator listed on the findings letter with any questions or concerns.
• If you disagree with our findings, please send documentation and/or regulations to support your rebuttal.

Any lack of response to the requested information may result in the following:

• A Magellan provider network representative contacting you.
• Retraction of payments for services not supported.
• Required reporting to the health plan and/or an external oversight agency.
• Onsite audit of claims and associated records.
• Initiation of claims pre-payment review.
• Termination from the Magellan network.

For more information

• Review Magellan's policy on audits and investigations in Section 4, of Magellan's National Provider Network Handbook (PDF) beginning on page 86, including:
• Cooperating with Magellan's audits and investigations.
• What to expect during a fraud, waste, abuse or overpayment audit or investigation. 

• Contact your Network representative with questions regarding your contract and obligations to provide medical records for review.
• If you have additional questions regarding our audit/investigation processes, contact the SIU via email at SIU@MagellanHealth.com or via our hotline at 1-800-755-0850 (you may remain anonymous).