Emergency and crisis services are inpatient and outpatient services that are needed to evaluate and stabilize a person who needs attention immediately to prevent harm to themselves or others.

A medical emergency is something so bad that a person with no medical training would say someone’s life or long-term health is at risk.

If you have a medical emergency:

• Call 911, or
• Go to the nearest emergency room or urgent care center.

You do not have to get approval from Magellan to get emergency services. You may use any hospital or other setting for emergency care. 

If you have a Mental Health or Substance Use Emergency (Crisis): 

A mental health crisis is when a person does something unexpected or suddenly acts in a way that:

• Puts them at risk of hurting themselves or others, and/or
• Prevents them from functioning or being able to care for themselves

If you need mental health crisis help, call 988 or text 988 to reach the Idaho Crisis and Suicide Hotline 24 hours a day, 7 days a week. 

If you or someone you know is in immediate danger of harm to self or others, go to the nearest crisis center or emergency room.

You do not have to get approval from Magellan to get mental health crisis services. You may use any crisis center, hospital or other setting for mental health crisis care. Any Idaho resident can get crisis help for free, regardless of health insurance coverage. 

If you go to a crisis center or emergency room, try to be prepared:

• Bring a list of the medicines you are taking. Include prescriptions, over-the-counter drugs, vitamins, and herbal supplements. 
• Take your Medicaid and/or other insurance ID cards, and information.
• If you have a guardian, take their name, phone number, and address.
• Tell the people treating you about your mental health or substance use concerns. This information will help them give you proper care.
• Tell them the name of your primary care provider and any mental health or substance use disorder providers you are seeing.
• Give them a copy of your psychiatric advance directive and/or your crisis and safety plan if you have either. You can learn about Psychiatric Advance Directives and Crisis and Safety plans in the Member Handbook.

If you don’t know if you need emergency/crisis help, call Magellan at 1-855-202-0973 (TTY 711), 24 hours a day, 7 days a week.

Emergency medical transportation 
Emergency transportation by an ambulance is covered by the Idaho Medicaid Plan. If you need an ambulance, call 911 or your local ambulance provider.

After-Hours and Urgent Care 
Urgent care is non-emergency healthcare for a person who needs to be seen quickly but can’t get an appointment with their regular provider. Urgent care is needed when you have an illness or situation that could quickly become an emergency or crisis. It can include care, lab work, and urgent medicines. Magellan providers must provide care within 24 hours for urgent situations, and within 7 days for routine appointments and specialty referrals. You do not have to get approval from Magellan to get after-hours care or urgent care for mental health or substance use problems.

How to get After-Hours/Urgent Care
If you have an urgent care need and cannot see your regular provider, call Magellan at 1-855-202-0973 (TTY 711), 24 hours a day, 7 days a week.
 

If you or your child needs mental health or substance use care, start by looking for a network provider who can help. Click here for the searchable provider directory. This directory is updated each day. As long as the care you want does not require a pre-authorization, you can see any network provider. You can read more about network providers and pre-authorization below.

You can also call Magellan at 1-855-202-0973 (TTY 711) to:

• Get help finding the right provider for your needs
• Ask for a list of providers near you who can meet your needs

A Magellan network provider (also called in-network provider) is one who agrees with Magellan to provide services for IBHP and signs a contract with us. These providers are in Magellan’s provider network. Magellan’s provider network is a large group of providers, hospitals, facilities, and other organizations who have agreed with Magellan to provide services for the IBHP and signs a contract with us. You can see any network provider and change to a new one at any time unless a court tells you that you have to stay with the one you have.

A non-network provider (also called out-of-network provider) is a provider who is not in Magellan’s provider network. If you need to visit a non-network provider, call Magellan at 1-855-202-0973 (TTY 711).

If you have Medicaid:

• You will not have to pay anything when you visit a Magellan network provider for Medicaid behavioral health services.
• When you become a Magellan Member, if you have been seeing an non-network provider, you may be able to see them for a certain amount of time. Call Magellan at 1-855-202-0973 (TTY 711) for more information.
• There may be a time when you need to use a provider, hospital, or facility that is not in our network. If this happens, call Magellan at 1-855-202-0973 (TTY 711). 

If you do not have Medicaid 

You may have to pay for some care from network providers and non-network providers. This is called a co-payment or cost share.

You might need a pre-authorization to get certain mental health or substance use disorder care. A pre-authorization (also called prior authorization) is an approval that may be needed for you to get a service or medicine. Read the Covered Services section of the Member Handbook or this website to see what care needs pre-authorization. If your provider thinks you need a service or medicine, they will ask Magellan for approval. We will review the request to see if it is medically necessary for you. You do not need a pre-authorization to get emergency services or help with a mental health crisis. 

What does “Medically Necessary” mean?
“Medically necessary” services and supports must meet professionally recognized standards and be supported by your behavioral health and medical records.

Services and supports are considered medically necessary if:

• They prevent, diagnose, or treat conditions that cause pain or malfunction, or put your life in danger, and
• There are no other services available or better to meet your needs that are less restrictive or costly

We use Medical Necessity Guidelines to see if a service is right for you. If you would like a copy of these Guidelines, visit MagellanofIdaho.com or call us at 1-855-202-0973 (TTY 711). 

How to ask for Pre-Authorization
If a pre-authorization is required for care your provider thinks you need, they will write the request. They may need information from you to complete the request. If you have a case manager or care manager, they may talk to them. Your provider will send all the required information to Magellan for us to review.

Magellan Review of Pre-Authorization Requests
Magellan will review the pre-authorization request and the information your provider submitted. If we have enough information to make a decision, we will tell you and your provider our decision.

If Magellan does not have enough information, we will tell your provider. We will give your provider some time to send us the new information. We will tell you and your provider Magellan’s decision once we have reviewed the new information.

You and your provider will get written notices telling you if the request is approved or not. If the request is not approved, it is called an Adverse Benefit Determination (ABD). An ABD is when a requested service or change in service is not approved, or only partly approved. An ABD can also happen if a provider doesn’t act on a request for services quickly enough.

If your Pre-Authorization Request is not Approved
If a service is not approved or only partly approved, we will send you and your provider an Adverse Benefit Determination Notice (ABD Notice). An ABD Notice is a letter a member or a provider gets when a requested service or change in service is not approved, or only partly approved. An ABD Notice can also be sent if a provider doesn’t act on a request for services quickly enough. 

The ABD Notice will explain why a service is not approved. If you disagree with the ABD Notice, you can appeal. An appeal request form and appeal instructions are included with the ABD Notice. 

For information on how to appeal a decision, see the Complaints, Appeals and Fair Hearings, section of this website. If you need help understanding the pre-authorization process, talk to your provider or call Magellan at 1-855-202-0973 (TTY 711).