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

Attention!

On July 1, Magellan Complete Care of Virginia becomes Molina Complete Care.

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

2021 Utilization Review NIA Matrix
2021 Utilization Review NIA Matrix – Interventional Pain Management
2021 Utilization Review NIA Matrix – Spine Surgery
2021 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
Mental Health Service Registration Form*new* June 2021
CMHRS & Behavior Therapy Continued Stay SRA
CMHRS & Behavioral Therapy Continued Stay SRA Form*new* June 2021
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
Therapeutic Day Treatment Initial SRA Form*new* June 2021
Intensive Outpatient Initial SRA Form*new* June 2021
Intensive Outpatient Continued Stay SRA Form – *new* June 2021
Assertive Community Treatment Initial SRA Form*new* June 2021
Assertive Community Treatment Continued Stay SRA Form*new* June 2021

Prior Authorization Requests

Prior Authorization Request Form
Prior Authorization List

Behavioral Health Inpatient Requests

Psychiatric Inpatient Initial Authorization
Psychiatric Inpatient Concurrent Authorization

Claims

eBusiness Submitter Profile Form
eBusiness User Companion Guide

 

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)

Maternity

Prenatal Notification Form
Newborn Notification Form

 

 

 

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