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
|Service||Initial Request Timeframe||Continued Stay Request Timeframe|
|Inpatient||Must be requested within 1 business day of admission.||
Must be requested by the start date.
|Psychiatric Residential Treatment Facility (PRTF), Therapeutic Group Home (TGH) Early and Periodic Screening, Diagnostic and Treatment (EPSDT) PRTF and EPSDT TGH*
||Must be submitted within 1 business day of admission but no earlier than 7 calendar days prior to admission.||Must be submitted by the requested start date but no earlier than 7 calendar days prior to requested start date.|
|Addiction and Recovery Treatment Services (ARTS) - other than Substance Use Case Management (see below)||Must be requested no later than 1 business day of admission but no earlier than 5 calendar days prior to admission.||Must be requested no later than the requested start date but no earlier than 5 calendar days prior to admission.|
|Therapeutic Foster Care Case Management (TFCCM)||Must be submitted within 10 business days of start date but no earlier than 30 calendar days prior to start date.||Must be submitted no later than the requested start date but no earlier than 30 calendar days prior to the start date.|
|All Community Mental Health and Rehabilitative Services (CMHRS) that require authorizations (other than TFCCM)||Must be submitted no later than the requested start date but no earlier than 30 calendar days prior to the start date.||Must be submitted no later than the requested start date but no earlier than 30 calendar days prior to the start date.|
|Crisis Intervention and Crisis Stabilization Registrations||Must be submitted within 1 business days of the requested start date.||Must be submitted within 2 business days of the requested start date.|
|Substance Use Case Management and Mental Health Case Management Registrations||Must be submitted within 2 business days of the requested start date and no more than 30 days prior to the start date.||Must be submitted within 2 business days of start date but no earlier than 30 calendar days prior to the start date.|
|Psychosocial Rehabilitation (PSR), Mental Health Peer Support, Substance Use Peer Support Registrations|
|Assertive Community Treatment (ACT)||Must be submitted within 1 business day of admission and no more than 30 calendar days prior to start date.|
|Mental Health Partial Hospitalization (MH-PHP) and Mental Health Intensive Outpatient (MH-IOP)||Must be submitted within 1 business day of admission and no more than 7 calendar days prior to start date.||Must be submitted no later than the requested start date but no earlier than 7 calendar days prior to the start date.|
*For Residential Special Considerations, Initial requests must be submitted within 5 business days of notification by the Residential Care Manager (RCM).
Independent Assessment, Certification and Coordination Team (IACCT) Submission Timeline
In situations where there is not consensus on the recommendation from the guardian and youth, IACCT Licensed Mental Health Provider (LMHP), and physician, or Medical Necessity (MNC) does not appear to be met, the IACCT LMHP must submit the IACCT assessment documents to Magellan prior to the recommendation meeting. If the IACCT recommends residential services during the recommendation meeting, the Certificate of Need (CON) must be submitted within 1 business day of the recommendation meeting in order to be considered timely.
In situations where the physician and IACCT LMHP’s recommendation align with the level of care the guardian and youth are requesting; the LMHP will submit the IACCT Service Authorization Request to Magellan within one business day of obtaining the physician’s recommendation.
Retro Medicaid Eligibility
For Retro Medicaid Eligibility, please refer to the manual specific to the service being provided.
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)
Please note that initial and concurrent requests for inpatient, psychiatric and several ARTS services (ASAM 3.3/3.5/3.7/4.0) require a phone review for authorization. A phone review is also required for retro-authorizations for ARTS ASAM 3.3/3/5/3.7/4.0. All CMHRS, Residential/IACCT SRAs as well inpatient psychiatric retro-authorizations are to be submitted online at www.magellanprovider.com.
Commonwealth of Virginia FIPS Locality Update Form Added 08-07-2017
Virginia DMAS Registration Updated 07-24-2017
Transition Authorization/Registration Request
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
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
Mental Health Services
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
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
Organization Provider Application Signature Page Added October 18, 2019
Therapeutic Day Treatment Initial Review -- Use through 6-30-21
Therapeutic Day Treatment Continued Stay Review -- Use beginning 7-1-21
Residential Continued Stay -- updated June 2021 (Use this version starting 7/8/21)
Please visit the Residential page for more Residential forms.
Project BRAVO Services
Assertive Community Treatment Initial Request Form -- For use beginning 7-1-21
Assertive Community Treatment Continued Stay Request Form -- For use beginning 7-1-21
Mental Health Intensive Outpatient and Mental Health Partial Hospitalization Initial Request Form -- For use beginning 7-1-21
Mental Health Intensive Outpatient and Mental Health Partial Hospitalization Continued Stay Request Form -- For use beginning 7-1-21
Treatment Foster Care Case Management—Initial Review Updated 06-2016
Treatment Foster Care Case Management—Continued Stay Review Updated 06-2016
Adverse Outcomes new online submission form -- posted March 7, 2017
Please note: Discharges should only be submitted below for authorizations with Magellan of Virginia. Please contact the respective health plan to submit discharges for authorizations from an MCO or Commonwealth Coordinated Care Plus (CCC Plus) plan.
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
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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