Drug & Alcohol Outpatient Non-Participating (Non-Par) Provider Request for Services Form

Drug and Alcohol Non Participating Provider Request for Services Form

Fields marked with an * are required

Request Type *

Initial Request
Concurrent Request: This should only be used for Children in Substitute Care/Probation or members placed outside of their county. Concurrent requests should not be submitted to extend continuity of care approvals beyond the initial request/60 days.

Rationale for Non-Par Request: *

No in-network/participating provider resources within thirty miles. A search for in-network/participating providers will be conducted by Magellan for this option.
Continuity of Care: Member has been in treatment with this provider and will be transitioned to an in-network/participating provider within 60 days. The 60 days will allow for the transition to be completed.
County Transition: Member is moving permanently to a new county. Please add the member’s new address in the space below.
Specialty Service: There is a clinical need that requires a specialty service that is not available in Magellan’s network. Please provide clinical justification for the specialty service.

Requested Authorization Start Date: *

(cannot be prior to the date this form is completed)

Up to 60 Days

Non-Par requests, if approved, will be for up to 60 days, with the exception for Children in Substitute Care (CISC) or members residing outside of their county, which may be approved for longer durations.

Following Information necessary

THE FOLLOWING INFORMATION IS NECESSARY TO BEGIN ALL NON-PAR OUTPATIENT DRUG AND ALCOHOL REQUESTS. INCOMPLETE FORMS WILL NOT BE PROCESSED.

Failure to meet the following criteria may result in our inability to process your request. Magellan’s Non-Par Policy states that all in network/participating provider options must be exhausted PRIOR to authorizing an out of network (Non-Par) provider request.

I attest

I attest, by reviewing and checking each of the criteria belowthat this non-par request is in compliance with the following:

This non-par request is being made prior to rendering services. *

In network provider options have been exhausted. This member was directed back to Magellan to locate an in-network/participating provider at one of the numbers below and/or I provided the member the local webpage https://www.magellanofpa.com which includes a provider search tool that shows all in-network/participating providers. *

Member Services

Member Services Contact Information:

Bucks County:
1-877-769-9784

Cambria County:
1-800-424-0485

Lehigh County:
1-866-238-2311

Montgomery County:
1-877-769-9782

Northampton County:
1-866-238-2312

Please list in-network/participating providers contacted below. Include their name, contact number/email and date contacted for each provider. *

This is NOT a retrospective request for authorizations. *

Service requests submitted after OP D&A services

Service requests submitted after providing Outpatient (OP) drug and alcohol services will not be processed using this form. If requesting out-of-network authorization for service dates that have already occurred, please review the retrospective process located here: Pennsylvania HealthChoices Handbook Supplement

I have checked EVS/PROMISe system and confirmed member eligibility prior to requesting this non-par. The member is currently active with Magellan Medicaid AND Magellan Medicaid is primary. Medicaid is always the payor of last resort. If this member has primary coverage, you MUST follow primary coverage rules and a non-par with Magellan Medicaid is not required. *

Check eligibility

You can check eligibility at the PROMISe website.

If this request is for continuity of care, I understand that if approved, I have up to 60 days to transition the member to an in-network/participating provider. The 60-day transition requirement does not apply to Children in Substitute Care (CISC). *

If the out-of-network/non-par services are being rendered via telehealth, the physical location of a licensed/enrolled site must be within 45 miles/ 60 minutes of the member’s home address. *

By entering my name below, I attest that this request meets the preceding criteria and I have completed all appropriate actions prior to submitting this request.

Full Name: *

HTML

Part 2: Contact Information

Phone Number of Person Completing Form: *

Email of Person Completing Form: *

Fax Number of Person Completing Form: *

Member's Full Name: *

Member's County *

Bucks
Cambria
Lehigh
Montgomery
Northampton

Member's Medicaid (MA) ID: *

10 of 10 Character(s) left

Member's Date of Birth (MM/DD/YYYY): *

Member's Diagnosis (ICD-10 code(s) and diagnosis name(s)): *

Name of Agency/Clinic Rendering Services *

Clinic License Name and License Number: *

Organization Provider NPI (National Provider Identifier): *

(NPI can be located here)

10 of 10 Character(s) left

Provider Tax Identification Number: *

(if unknown, reach out to your billing department)

9 of 9 Character(s) left

PROMISe/MA ID (13 digits (including 4-digit location number)): *

(if you do not know this, please access at PROMISe website)

13 of 13 Character(s) left

Divider

HTML

Part 3: Provider Type (08) and Specialty (184)

Choose your requested service codes

Choose your requested service codes:

H0034 SA, UB-Medication Training & Support (No Script) RN (Max Units= 8) unit =15 minutes

CRNP

90792 U8, SA, HF-MAT Services Only, Psychiatric Diagnostic Interview/w medical services (Max Unit=1)
90792 SA, HF Diagnostic Evaluation/w medical services - (Max Unit=1)
99213 SA, HF -Office Outpatient Visit Established Patient (Max Unit=8)

Counseling Services

90791 UA, HF-Initial diagnostic interview, w/o medical services (Max Unit=1)
90832 HF-Psychotherapy with patient and/or family member (Max Units=8)
90834 HF-Psychotherapy with patient and/or family member (Max Units=8)
90837 HF-Psychotherapy with patient and/or family member (Max Units=8)
90847 HF-Family Psychotherapy with patient present (Max Units=8)
90853 HF-Group Therapy (other than of a multiple-family group) (Max Units=32)

Pyschiatrist

90792 U8, HF, AF-MAT Services Only, Psychiatric Diagnostic Interview/w medical svcs (Max Unit=1)
90792 HF, AF-Psychiatric Diagnostic Interview (Max Unit=1)
99213 HF, UB -Office Outpatient Visit, Established Patient (Max Units=8)
99213 U8,HF,UB -Office Outpatient Visit, Established Patient (Max Units=8)

Provider Type 08 and Specialty Code 184

H0035 HF - ASAM 2.5 D&A Partial (Max Unit=480)

Provider Type 08 and Specialty Code 084

H0020 UB, HF Methadone Maintenance (Max Unit=60)

Provider Type 11 and Specialty Code 128

H0015 HF ASAM 2.1 D&A Intensive Outpatient (Max Unit=480)

Rendering Provider Site Address (must align with Promise ID): *

Provider Billing Address: *

HTML

Part 4: Signature

The contact information below will be used for exchange of information related to the non-par contract. Faxes will be sent to the fax number listed above.

The contact information below will be used for exchange of information related to the non-par. Faxes will be sent to the fax number listed above.

Phone number of Person Completing form: *

10 of 10 Character(s) left

Email of Person Completing form: *

Signature of Person Completing this form: *

Additional Information:

Supporting Documents (For example: primary denial letters, letters that say not a covered benefit under the primary insurance, screenshot of member eligibility termination from primary coverage.)

Completion of this form does not imply approval of the non-par request

Completion of this form does not imply approval of the non-par request

What to expect next:

Magellan will review request within two business days and determine if approved or denied. Notification will be sent to the fax number provided above.

1. This form is required for billing and must be referenced for appropriate codes and modifiers. Failure to use approved codes and modifiers will result in claims denials.

2. For additional information please visit the claims section of our Provider Handbook.

If you would like a PDF version of this form, please use your browser to Print and then select “Print to PDF” to save a copy to your computer.

HTML

For Magellan Internal Use Only

Cannot Process Reason

The member is not able to be verified as eligible with Magellan Medicaid.
Magellan Medicaid is not the primary carrier for this member. Medicaid is always the payor of last resort. If member has primary coverage, you MUST follow primary coverage rules and a non-par with Magellan is not required.
The provider’s name, address where service was provided, Pennsylvania Medical Assistance Provider Number (MPI), Tax ID Number (TIN) and/or provider contact information was not accurate.
The provider is not enrolled in Pennsylvania Medical Assistance program.
In-network is not exhausted (Rationale: Provider not participating/in network. There is a participating provider within the PAHC network who can provide this service).
Justification for request is not received.

If you are a human seeing this field, please leave it empty.