Provider Tools

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

Please note: To use these fillable PDF forms, after opening the file you will have to go to "Options" in your Adobe software and select "Trust this host". 

Consent to Release PHI Form

AUD PHI Form -- member AUD PHI form

Service Request Authorizations (SRAs)

Registration Request

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

Virginia DMAS Registration Updated 07-24-2017

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 under provider portal.

Retro Inpatient Review Added 12-03-2015

Governor's Access Plan (GAP)

Crisis Stabilization SRA for GAP Updated 01-2016

Addiction and Recovery Treatment Services (ARTS) 

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 -- this version required 7/1/18

ARTS Service Authorization Extension Request form -- this version required 7/1/18

ARTS Substance Use Case Management Registration form effective 4/1/17

Community Mental Health Rehabilitative Services (CMHRS) and other State Plan Option Services

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

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

EPSDT Behavioral Therapy—Initial Review Updated 07-2016
EPSDT Behavioral Therapy—Continued Stay Review Use this version through 7/31/18
EPSDT Behavioral Therapy—Continued Stay Review Use this version starting 8/1/18
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

Residential

Residential Level A Initial Review 05-09-2016
Residential Level A Continued Stay Review 05-09-2016

Family Engagement Notification Form
IACCT Service Request Authorization (SRA) -- updated April 2018
Residential Initial Request -- updated 05-15-2017
Residential Continued Stay -- updated January 2018

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

Please visit the Residential page for more Residential forms. 

Retro Outpatient Mental Health Initial or Continued Stay

PLEASE NOTE: Dates of service 7-1-2017 or later DO NOT require an authorization

Outpatient Initial Authorization Updated 07-2016
Outpatient Continued Stay Review Updated 07-2016

Psychological Testing Request Updated 10-15-2014

Case Management

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

Other Forms

Acute inpatient auto fax member letter opt-in form

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

Discharge

VA DMAS Discharge Form - online version updated 11-2016

Inpatient Discharge Checklist Added 04-27-15

Grievance Reporting Form

Grievance Reporting Form - online version Added 06-2015

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

 

 

 

The Adobe Reader is required to view PDF files.