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Magellan Health

PROVIDER RECONSIDERATION REQUEST/CLAIM RECONSIDERATION 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.

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 your request as you usually would to Magellan’s clinical department.

PROVIDER’S INFORMATION
RECONSIDERATION INFORMATION




Complete this section for Claim Reconsiderations