- Magellan of Virginia - https://www.magellanofvirginia.com -

Forms

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

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.


Mental Health Services (other than those listed below) 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.


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.


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 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.


Assertive Community Treatment (ACT) Must be submitted within 1 business day of admission and no more 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.


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.


Mobile Crisis, 23 Hour Crisis Stabilization, Residential Crisis Stabilization Unit Registrations Must be submitted within 1 business day of admission. Not Applicable


Community Stabilization Authorization Must be submitted within one business day. Must be submitted by the requested start date and no earlier than 48 hours prior to the requested start date.


Residential Crisis Stabilization Authorization (for services beyond 5 calendar days and 5 units) Must be submitted by the requested start date and no earlier than 24 hours prior to the requested start date. Must be submitted by the requested start date and no earlier than 24 hours prior to the requested start date.


Multisystemic Therapy and Functional Family Therapy Must be submitted within 1 business day of admission. Must be submitted by the requested 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”. 

Member AUD PHI form
Consent to Release PHI Form

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.

Please call Magellan at 1-800-424-4046 to request a phone authorization or if you are having difficulties with submitting an SRA online.

Registration Request

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

URL

Updated September 2022
Virginia DMAS Registration

Word Doc

Transition Authorization/Registration Request

Word Doc (.DOCX)
Transition Authorization/Registration Request Form

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.

Added 12-03-2015
Retro Inpatient Review

Word Doc. (.DOCX)

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.

This version required 7/1/18
ARTS Initial Service Authorization Request form

Word Doc (.DOCX)

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

Word Doc (.DOCX)

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

Word Doc (.DOCX)

Mental Health Services

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

Word Doc (.DOCX)

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

PDF

Updated 07-2016
EPSDT Behavioral Therapy—Initial Review

Word Doc (.DOCX)

Use this version through 7/31/18
EPSDT Behavioral Therapy—Continued Stay Review

Word Doc (.DOCX)

Use this version starting 8/1/18
EPSDT Behavioral Therapy—Continued Stay Review

Word Doc (.DOCX)

Updated 10-09-2014
EPSDT Behavioral Therapy—Service Transfer Request

Word Doc (.DOCX)

Added 10-09-2014
EPSDT Behavioral Therapy Assessment Over 5 Hours

Word Doc (.DOCX)

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

Word Doc (.DOCX)

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

Word Doc (.DOCX)

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

Word Doc (.DOCX)

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

Word Doc (.DOCX)

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

Word Doc (.DOCX)

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

Word Doc (.DOCX)

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

Word Doc (.DOCX)

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

Word Doc (.DOCX)

Added October 18, 2019
Organization Provider Application Signature Page

PDF

Updated May 1, 2017
Therapeutic Day Treatment Initial Review

Word Doc (.DOCX)

Updated May 1, 2017
Therapeutic Day Treatment Continued Stay Review

Word Doc (.DOCX)

Residential

Please visit the Residential page for more Residential forms.

Updated April 2018
IACCT Service Request Authorization (SRA)

Word Doc (.DOCX)

Updated 05-15-2017
Residential Initial Request

Word Doc (.DOCX)

Updated January 2018
Residential Continued Stay

PDF

Project BRAVO Services

 

For use beginning 7-1-21
Assertive Community Treatment Initial Request Form

PDF

For use beginning 7-1-21
Assertive Community Treatment Continued Stay Request Form

PDF

For use beginning 7-1-21
Mental Health Intensive Outpatient and Mental Health Partial Hospitalization Initial Request Form

PDF

For use beginning 7-1-21
Mental Health Intensive Outpatient and Mental Health Partial Hospitalization Continued Stay Request Form

PDF

For use beginning 12-1-21
Applied Behavior Analysis Initial Request Form

PDF

For use beginning 12-1-21
Applied Behavior Analysis Continued Stay Request Form

PDF

For use beginning 12-1-21
Functional Family Therapy Initial Request Form

PDF

For use beginning 12-1-21
Functional Family Therapy Continued Stay Form

PDF

For use beginning 12-1-21
Multisystemic Therapy Initial Request Form

PDF

For use beginning 12-1-21
Multisystemic Therapy Continued Stay Form

PDF

For admission dates of 9-1-22 and later
Community Stabilization Initial Service Authorization Form
For service dates of 9-1-22 and later
Community Stabilization Continued Stay Authorization Form
For use for admission dates of 9-1-22 and later
Community Stabilization Referral Form
For use beginning 12-1-21
Residential Crisis Stabilization Unit Continued Stay Form 

PDF

This service only requires an authorization for services beyond 5 calendar days – For use beginning 12-1-21

Updated September 2022
Magellan Registration Form

PDF

For use for 12-1-21 through 8-31-22
Community Stabilization Continued Stay Form

PDF

For use for dates of service 12-1-21 through an admission date of 8-31-22 and prior.

Case Management

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

PDF

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

PDF

Other Forms

PDF
Acute inpatient auto fax member letter opt-in form

Adverse Outcome Reporting

Click here for the online submission form.

Discharge

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.

Updated 11-2016
VA DMAS Discharge Form - online version

URL

Added 04-27-15
Inpatient Discharge Checklist

PDF

Grievance Reporting Form

Added 06-2015
Grievance Reporting Form - online version

URL

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.

Click here to access the form.