Magellan Health

For Providers

Forms

Before submitting any form to Magellan, please refer to this webpage for the most up-to-date version of the form. Thank you.

Use the forms below as needed to support member care and administrative functions.

Fax completed Registrations with ICD 10 autism code and Retro Outpatient Authorization faxable forms to 1-888-656-2168

Acute inpatient auto fax member letter opt-in form

Adverse Outcomes new online submission form -- posted March 7, 2017

Registration Request

Commonwealth of Virginia FIPS Locality Update Form Added 08-07-2017 

Virginia DMAS Registration  Updated 07-24-2017

Grievance Reporting Form

Grievance Reporting Form - online version  Added 06-2015

Inpatient Psychiatric Submission Request

TDO Admissions -- Please call Magellan at 800-424-4046 for an Administrative Authorization
Non-TDO Initial Review -- Please call Magellan at 800-424-4046 or submit request online via VA DMAS Registration/Authorization link.

Retro Inpatient Review   12-03-2015

Governor's Access Plan (GAP)

UPDATED Crisis Stabilization SRA for GAP  Updated 01-2016

ARTS Service Request Authorizations (SRA)

PLEASE NOTE: There is one SRA for initial requests for all ARTS services requiring an authorization and one for continued stay requests.

ARTS Initial Service Authorization Request form (MS Word fillable) effective 4/1/17

ARTS Service Authorization Extension Request form (MS Word fillable) effective 4/1/17 

Community Mental Health Rehabilitative Services and other State Plan Option Services

CMHRS At-Risk Of Physical Injury Screening DMAS P502 Added 06-02-2015

Residential Level A and B Initial Review  05-09-2016

Residential Level A and B Continued Stay Review  05-09-2016

Residential Level C Initial Review  05-09-2016

Residential Level C Continued Stay Review  05-09-2016  

The following Residential SRAs can be used starting July 1, 2017

Family Engagement Notification Form
IACCT Service Request Authorization (SRA) -- updated May 2017
Residential Initial Request -- updated 05-15-2017
Residential Continued Stay -- updated 05-15-2017

ACEs 1-11 scoring tool
ACEs 1-11 survey - printable
ACEs 12-17 scoring tool
ACEs 12-17 survey printable

Day Treatment/Partial—Initial Review  Updated 05-09-2016
Day Treatment/Partial—Continued Stay Review  Updated 05-09-2016

EPSDT Behavioral Therapy—Initial Review   07-2016
EPSDT Behavioral Therapy—Continued Stay Review  07-2016
EPSDT Behavioral Therapy—Service Transfer Request  Updated 10-09-2014
EPSDT Behavioral Therapy Assessment Over 5 Hours  Added 10-09-2014

Intensive Community Treatment—Initial Review   Updated 05-09-2016
Intensive Community Treatment—Continued Stay Review  Updated 05-09-2016

Intensive In-Home Services—Initial Review  Updated 11-01-2016
Intensive In-Home Services—Continued Stay Review  Updated 11-01-2016

MHSS Retro Prior to 12-1-2013  Added 12-13-2013

Mental Health Skill-building Services (Adult) Initial Review Updated May 1, 2017

Mental Health Skill-building Services (Adult) Continued Stay Review  Updated May 1, 2017

Mental Health Skill-building Services (Adolescent) Initial Review  Updated May 1, 2017

Mental Health Skill-building Services (Adolescent) Continued Stay Review  Updated May 1, 2017

Therapeutic Day Treatment Initial Review -- Updated May 1, 2017
Therapeutic Day Treatment Continued Stay Review -- Updated May 1, 2017

Treatment Foster Care Case Management—Initial Review  Updated 06-2016
Treatment Foster Care Case Management—Continued Stay Review  Updated 06-2016

Outpatient Mental Health or Substance Use Disorder Requests—Initial or Continued Stay

Initial Outpatient Authorization 07-2016

Outpatient Continued Stay Review  07-2016

Psychological Testing Request  Updated 10-15-2014 

Case Management

Case Management Retro Review  Added 02-25-2014

Discharge

VA DMAS Discharge Form - online version  updated 11-2016

Inpatient Discharge Checklist  Added 04-27-15

AUD PHI Form -- member AUD PHI form

Reconsideration Form

Please be advised, you may only request a reconsideration for dates of service that have been non-authorized by Magellan. If you wish to obtain authorization for different dates of service, please submit to Magellan’s clinical department your request.

You have the right to request a Reconsideration of Magellan of Virginia’s (Magellan) initial non-authorization of service. Your Reconsideration request must be received within 30 calendar days from the date of our initial non-authorization letter or the date of the remittance advice containing the denial for requesting reconsideration. Reconsideration requests received after the 30 day time limit will be denied as untimely.

DIRECTIONS: Use this form to submit a request for reconsideration of Magellan’s non-authorization of services or in response to a claim denial outlined in your Explanation of Benefit. The areas of the form notated with a red asterisk (*) are required. You cannot submit the form if those areas are blank. Attach any additional documentation related to your reconsideration by utilizing the “UPLOAD” or “Browse” button. Additional documentation may include clinical information, VICAP, claim forms, Explanation of Benefit, etc. It is recommended that you submit additional information addressing each criteria or requirement identified as not met in the non-authorization letter. Please give specific details supporting why you believe these criteria or requirements are met.

Reconsideration Form - online version  Added 06-2015

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Contact Us

Magellan Members
Toll-free:1-800-424-4046
TDD: 1-800-424-4048
TTY: 711
Email

Magellan Providers
For questions about credentialing, contracting, provider website issues or general provider concerns, please contact us or call 1-800-424-4536.

For claim, authorization, discharges or clinical questions: email or call 1-800-424-4046.

Fraud and Abuse
1-800-755-0850
Special Investigations Unit Email: SIU@magellanhealth.com.

For quality of care concerns, general questions or comments, please call:
Toll-free: 1-800-424-4046