Forms - Provider Portal
What’s on this page
Forms
What’s on this page
EAP Forms
- Use these forms when providing Employee Assistance Program (EAP) services.
Retain completed clinical forms in the client's chart.
Fill out forms completely and/or note why a section cannot be completed.
See the EAP provider handbook supplement for policies and procedures required for rendering services to EAP clients.
Important Note: EAP Registration Packets
In most cases, Magellan does not send EAP Member Registration Packets by mail. Providers can view and print the packet documents securely online. Read more.
Instructions for EAP Initial Session Documentation
Generic Standard Statement of Understanding (PDF) (English)
Federal Occupational Health (FOH) Statement of Understanding (PDF)
Each client of adult age receiving services must sign a Statement of Understanding (SOU) indicating that they understand the nature of EAP services. For minors, a parent or legal guardian must sign the SOU, unless under applicable state law a minor can consent to treatment. A copy of the signed SOU is to be offered to the client. Use the company-specific SOU which is available in the online EAP Registration packet. Note: The Federal Occupational Health (FOH) EAP uses a custom Statement of Understanding, see page 14 of the FOH supplement appendix (PDF).
Client Information Form (PDF)
This form is to be completed by the client.Clinical Assessment (PDF)
All clients age 12 and older are to be assessed for alcohol and other drug use, risk factors, and job/school impact. Include a risk assessment in the clinical assessment.Counseling Plan (PDF)
Initiate this form during the first session based on the clinical assessment.
One of the best things we can do for members who have been diagnosed with a substance use disorder is to ensure they get connected with follow-up care within 14 days of diagnosis and have two additional visits in the next 34 days to ensure continuity of care. Educating members on the importance of treatment for their condition and assisting the member in making follow-up appointments with a treating provider can go a long way toward improving outcomes.
According to the National Institute on Drug Abuse, “most people who get into and remain in treatment stop using drugs, decrease their criminal activity, and improve their occupational, social, and psychological functioning.”[i] Additionally, substance use disorder treatment (including medication-assisted treatment) has shown to reduce mortality and AOD-related morbidity rates.[ii] [iii]
Facilities and outpatient providers play a vital role in helping members receive timely initiation and engagement of alcohol and other drug (AOD) abuse or dependence treatment (IET).
- Facilities: Including these elements in your planning (PDF) can help ensure members receive the services they need (includes coding guide)
- Outpatient provider: Helping patients receive timely ambulatory follow-up with these tips (PDF) can result in more successful outcomes (includes coding guide)
- Initiation and engagement of alcohol and other drug abuse or dependence treatment (IET): slide deck (PDF)
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[ii] https://www.samhsa.gov/medication-assisted-treatment
[iii] National Institute on Drug Abuse (NIDA). (2018). How effective is drug addiction treatment? https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/how-effective-drug-addiction-treatment
Progress Notes (PDF) Progress Notes need to be completed only when there is more than one session.
Follow-Up Summary (PDF)
After completing the EAP services, clients must receive a follow-up contact within two to four weeks after the last session. When you make a referral for continued care beyond the EAP, the follow-up call must confirm that the client has followed through with the referral.
To receive payment for EAP services rendered, you must complete the Employee Assistance Service Information (EASI) Form.
Online EASI Form – Use the online application to conveniently and easily submit your EASI forms. Simply sign in with your secure username and password, and click on Submit an EASI Form on the left-hand menu (under My Claims).
EASI Form – hard copy for faxing or mailing (PDF)
EASI Form Instructions (PDF)
EAP Reimbursement Contact Information (PDF)
You must submit the EASI form within 90 days of the end date indicated on the referral sheet, found in the EAP member registration packet for each specific case. Please refer to the EAP registration packet for the specific billing address.
EAP EFT Form (PDF 100K) – to request electronic funds transfer to your bank account
Only use as needed
Substance Abuse/Chemical Dependency Assessment (PDF)
If your assessment or the result of the chemical dependency (CD) screening indicates a possible CD issue, the Substance Abuse/Chemical Dependency Assessment form must be completed. This form documents that you have conducted a CD assessment.
Depression Screening (PDF)
This optional tool can be used to assist in the assessment of client depression.
Case Management Notes (PDF)
Case Management Notes are for tracking contacts with other providers (PCP, psychiatrists, other therapists, etc.) or other interested parties such as family members contacted for supplementary information.
Self-Referral (PDF)
This form must be completed if, after completing all EAP sessions, the member chooses to remain with the EAP provider for ongoing treatment.
See the EAP provider handbook supplement for policies and procedures required for rendering services to EAP members
If you have questions about any of the forms, call our national Provider Services Line at 1-800-788-4005.
Management Referral forms are specific forms required for legal and mandatory referrals. Please also refer to EAP Handbook Supplement Appendix H (PDF) to review the Workplace Support Mandatory Referral Process and Staffing Guide for Management Referrals. Your Workplace Support consultant will provide you with the Care Plan form specific for each case.
Statement of Understanding -- Mandatory (PDF)
Authorization to Use of Disclose Protected Health Information -- Mandatory (PDF)
Statement of Understanding -- Formal (PDF)
Authorization to Use or Disclose Protected Health Information -- Formal (PDF)
Guidelines to Fill Out Mandatory and Formal AUD and SOU (PDF)
Admin Forms
Sign in securely on this website to access the online Provider Data Change Form. Most changes you make will upload in real-time to Magellan's systems, ensuring we always have the most up-to-date information for your practice. You can securely update:
Billing, mailing, service and home addresses
Phone and fax numbers
Email addresses
Hours of operation
Taxpayer Identification Number
License and specialty information
Roster members
And much more.
To review your practice information and make changes, sign in and click Display/Edit Practice Information from the left menu.
Medicaid providers must complete and submit the Medicaid Disclosure Form (PDF). Magellan is contractually obligated to collect the information on this form and will provide it to the health plan and/or State Medicaid agency. We highly encourage you to securely sign in to this website to complete the online version of the Medicaid Disclosure Form, rather than mailing a hard copy.
If you change your billing Taxpayer Identification Number (TIN), you must complete and submit an online Form W-9 listing the legal name of the payee and the type of TIN – Employer Identification Number (EIN), Social Security Number (SSN), or Individual Taxpayer Identification Number (ITIN).
Sign in securely on this website to access the online W-9. Once signed in:
Click Display/Edit Practice Information on the left-hand menu under MyPractice.
On the Provider Data Change Form tab, select the appropriate MIS/TIN combination and click Go.
Click W-9 Form.
To submit a new form, click Submit Online.
For inquiries regarding a Form 1099 issued by Magellan, contact Jackie Laberer at 314-377-7522.
For inquiries regarding a Form 1099 issued by ECHO Health, call 1-888-834-3511.
Clinical Forms
In support of our commitment to quality care, we require our providers to maintain organized, well-documented member treatment records that reflect continuity of care. We expect providers to document all aspects of treatment in a timely manner, including face-to-face encounters, telephone contacts, clinical findings and interventions.
NOTE: Forms may not be compliant with some state regulations. It is the provider's responsibility to ensure that his/her documentation is compliant with all applicable state laws.
Initial Evaluation (PDF)
Progress Note (PDF)
Treatment Plan (PDF)
Discharge Summary (PDF)
This Treatment Record Review tool (PDF) is not required in the member's file; however, it is is used by Magellan reviewers when evaluating treatment records during a site visit and is posted for reference purposes only. For more information on treatment record reviews and site visits, please see the Magellan Provider Handbook (PDF).
This is a sample Authorization to Disclose PHI to PCP form (PDF) that enables the behavioral health provider to share protected health information (PHI) with the primary care physician (PCP). The provider is encouraged to have each member sign and date the form at the outset of new episodes of care.
A completed Clinician Communication Form (PDF) allows the behavioral health provider to inform the PCP that behavioral health treatment is occurring, and also provides information on how to contact the behavioral health provider if needed. Other information in the communication can include member diagnosis, a clinical summary, treatment plan changes, member safety issues, laboratory tests ordered, and medication issues or changes.
Magellan believes in protecting all member’s rights to receiving care delivered with dignity, and respect. Our official statement is published and downloadable in the appendix of our National Provider Handbook.
Members' rights and responsibilities apply whether services are provided virtually or in-person.
First Appointment
Download a copy of Magellan’s Members’ Rights and Responsibilities Statement. Review the statement with members in your care at their first appointment. Both you and the member should sign it. Retain a copy of the signed copy in the member’s record.
We recommend that you also inform the members in your care of the procedures to follow if a clinical emergency occurs, confidentiality scope and limits, treatment options, etc. Take the opportunity to obtain consent to share information with their primary care physicians or other providers; this will improve the efficiency of coordinating care.
Only use as needed
Substance Abuse/Chemical Dependency Assessment (PDF)
If your assessment or the result of the chemical dependency (CD) screening indicates a possible CD issue, the Substance Abuse/Chemical Dependency Assessment form must be completed. This form documents that you have conducted a CD assessment.
Depression Screening (PDF)
This optional tool can be used to assist in the assessment of client depression.
Case Management Notes (PDF)
Case Management Notes are for tracking contacts with other providers (PCP, psychiatrists, other therapists, etc.) or other interested parties such as family members contacted for supplementary information.
Self-Referral (PDF)
This form must be completed if, after completing all EAP sessions, the member chooses to remain with the EAP provider for ongoing treatment.
See the EAP provider handbook supplement for policies and procedures required for rendering services to EAP members
If you have questions about any of the forms, call our national Provider Services Line at 1-800-788-4005.
Before administering testing, complete and submit the Magellan Psychological Testing Preauthorization Request Form and submit it online (preferred method), or by fax or mail to the appropriate Magellan Care Management Center for review. An administrative non-authorization will occur if preauthorization is not obtained in routine circumstances.
Each Magellan Care Management Center has its own dedicated fax line for the submission of testing request forms; call the customer service number on the member’s insurance ID card to learn the appropriate fax number. Submitting your request to the incorrect Care Management Center will delay processing.
Sign in to this website and use the Request Member Care application to enter psychological testing preauthorization requests
Psychological Testing Preauthorization Request Form (PDF) for handwritten completion
Specific state laws and client requirements may demand modified medical necessity criteria. If you have members in care under any of the benefit plans, in any of the states, or employed by any of the employers requiring modified criteria, please refer to the appropriate medical necessity criteria below. For more information on the use of the below criteria, contact the medical director at your Magellan Care Management Center.
- American Society of Addiction Medicine (ASAM)
- An Introduction to The ASAM Criteria for Patients and Families (PDF)
Licensee's use and interpretation of the American Society of Addiction Medicine’s ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits.
California |
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Louisiana |
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New Mexico |
New Mexico Prior Authorization Requirements and Clinical Criteria |
Pennsylvania |
Pennsylvania HealthChoices – criteria for providers serving members of the HealthChoices Program in Pennsylvania can be found at www.MagellanofPA.com. |
Texas |
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Virginia |
Paper Claim Forms
We encourage providers to submit electronic claims, which allows for earlier detection of errors, drastically reducing the likelihood of claims being rejected or denied for payment, and often results in faster processing.
