Magellan Health

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For Providers

Forms

Use the forms below as needed to support member care and administrative functions.

Clinical Forms

Obtaining Prior and Continuing Authorizations for Community Based Services (CPST & PSR, FFT, and Homebuilders Services)

Freedom of Choice Forms:

  • This Freedom of Choice form is to be used with youth Coordinated System of Care (CSoC) waiver services.
  • This Member's Freedom of Choice form (Revised: 12/01/2015) is to be used for all youth members prior to service authorization.
  • The Freedom of Choice form is also available in Spanish and Vietnamese.

Psychiatric Hospitalization:

  • We are pleased to inform you Case Logix is now available online.  Web Case Logix provides facilities the ability to request initial authorizations for inpatient psychiatric services online thru our provider website. This function is now available for all Louisiana Behavioral Health Partnership approved hospital providersAccess instructions on using Case Logix.
  • Read our provider Frequently Asked Questions.
  • Certification of Need for Psychiatric Hospitalization.

 Psychological Testing*:

* Complete and submit the form above when authorization for psychological testing is being requested. In most cases, an initial assessment by a behavioral health care provider must be administered before psychological testing will be authorized.To avoid potential issues with reimbursement, psychological testing is not to be initiated until an authorization has been received.

Claims/Payment-Related Forms

Electronic Payment Is Required Effective July 1. If you are not currently receiving payments via electronic funds transfer (EFT), please sign up as soon as possible. EFT is a fast, secure and environmentally friendly method to receive payments directly into your bank account.

Complete and submit this form to Magellan to request that your claims payments be directly deposited to your business bank account.

 

If you use a clearinghouse, complete this form and contact the clearinghouse to sign up for ERA, which is the electronic method for providers to receive Explanation of Benefits (EOB), Explanation of Payment (EOP) and claims denial information.

 

If you submit claims directly to Magellan, complete this form in order to register / terminate for your Electronic Remittance Advice ERA).

Other Forms

  • CSoC Needs Reporting Form - A CSoC member’s Plan of Care (POC) outlines his/her specific service needs.  When the services listed are not being received as outlined, this form is completed by the WAA and helps identify and describe the needs, barriers, or issues of provider types that impact service delivery in order for appropriate action steps to occur and find resolution. 
  • CSoC MCO Referral Form – For the Bayou Health Plans to submit referrals to Magellan
  • CSoC Discharge Form – For the Wraparound Agency to submit to Magellan when child/youth is transitioned or discharged out of CSoC.
  • CSoC Adverse Incident Reporting Form – For providers reporting an adverse incident occurrence.
  • CSoC Member Appeal Form – For members to submit formal appeal in writing.
  • LA CSoC Interested Provider Form and W-9 Form - For providers interested in becoming a Magellan Provider.

 

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Recovery & Resiliency

e-Courses

Magellan has partnered with national experts in behavioral health recovery and resiliency to offer e-courses.