Provider Forms

Here you can find all your provider forms in one place. If you have questions or suggestions, please contact us.

Provider Relations phone: 1-800-424-4524
Provider Relations email: MCCVAProvider@MagellanHealth.com

Addiction Recovery Treatment Services (ARTS)

Service Authorization – Initial Request Form
Service Authorization – Extension Request Form
Attestation ASAM Levels 2.1 to 3.7 Form
Peers Registration Request Form
Substance Use Case Management Registration Form

Appeals

Appeals Form

 

 

Authorizations/Utilization Management

Utilization Review Matrices

2019 Utilization Review NIA Matrix – IPM and MSK
2019 Utilization Review NIA Matrix – Radiation Oncology
2019 Utilization Review NIA Matrix – Cardiac
EPSDT Coding Guide

CCC Plus Standardized Forms for CMHRS

CCC Plus Service Registration Form
CMHRS & Behavior Therapy Continued Stay SRA
Day Treatment/Partial Hospitalization Rehab Services Initial SRA
EPSDT Behavior Therapy Initial SRA
Intensive Community Treatment Rehab Services Initial SRA
Intensive In-Home Initial SRA
Mental Health Skill-Building Initial SRA
Psychosocial Rehabilitation Initial SRA
Therapeutic Day Treatment Initial SRA

Prior Authorization Request

Prior Authorization Request Form
Prior Authorization List

Claims

eBusiness Submitter Profile Form
eBusiness User Companion Guide
Returned Claims Letter
Service Verification Letter 

Critical incidents

Critical Incident Report Form

 

 

General

Telehealth Services Provider Attestation Form
Medicaid Disclosure Form/MDF
Hospice Enrollment – Disenrollment Authorization Request
Nursing Facility Admission, Discharge, or Level of Care Change (DMAS-80)
Home and Community Based Services Request Form (DMAS-98R)

Network Participation (Contracting/Credentialing)

Provider Information Form
Provider Data Change Form
Organization Provider Application Form
MCC of VA Health Roster Template (XLS)
Site and Services Form
W9 Form

Pharmacy

CCC Plus Service Authorization Forms

Antimigraine Agents, Others SA Form
Antipsychotics in Children SA Form
Cytokine CAM Antagonists SA Form
Oral Buprenorphine Products SA Form
Growth Hormone SA Form
Hepatitis C Antivirals Non-Preferred SA Form
Hepatitis C Antivirals Preferred SA Form
Methadone SA Form
Narcolepsy Meds SA Form
Otrexup or Rasuvo SA Form
Prescription Drug SA Form
Proton Pump Inhibitors SA Form
Short and Long Acting Opioids SA Form
Stimulants & ADHD Meds For Children SA Form
Sublocade SA Form
Synagis SA Form

Medallion 4.0 Service Authorization Forms

Antimigraine Agents, Others SA Form
Antipsychotics in Children SA Form
Cytokine CAM Antagonists SA Form
Oral Buprenorphine Products SA Form
Growth Hormone SA Form
Hepatitis C Antivirals Non-Preferred SA Form
Hepatitis C Antivirals Preferred SA Form
Methadone SA Form
Narcolepsy Meds SA Form
Otrexup or Rasuvo SA Form
Prescription Drug SA Form
Proton Pump Inhibitors SA Form
Short and Long Acting Opioids SA Form
Stimulants & ADHD Meds For Children SA Form
Sublocade SA Form
Synagis SA Form