Get Behavioral Health Outpatient Prior Authorization Form - Magellan ...

Filling out the Behavioral Health Outpatient Prior Authorization Form is an essential step in securing necessary behavioral health services. This guide provides clear instructions for completing the form online, ensuring you submit a comprehensive and accurate request.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing enrollee demographic and medical information. Fill in the enrollee's name, member number, and date of birth. Indicate if the enrollee resides in an assisted living facility, and if so, include the facility's name and phone number.
3. Enter provider and facility information, including the provider name, tax identification number, address, zip code, contact person, phone number, and fax number. Specify the requested start and end dates for services.
4. Outline the requested level of service, including specific units for various treatment types such as targeted or intensive case management, psychosocial rehabilitation, and electroconvulsive therapy. Note any previous authorization numbers if applicable.
5. Detail the reason for the requested service along with the anticipated length of stay. Include the referral source and context as to why the service is needed now.
6. Provide information about the clinical diagnosis by listing all five axes, current psychosocial stressors, and both current and past year Global Assessment of Functioning (GAF) scores.
7. Conduct a mental status exam and risk assessment, addressing any suicidal or homicidal thoughts and plans.
8. List all medications the enrollee is currently taking, both physical and behavioral, including dosages and frequency.
9. Summarize psychosocial history, noting any experiences of abuse or neglect, cultural influences, legal issues, or substance abuse.
10. Provide details about the enrollee's school or work experience, including any relevant information such as grades, special education status, and records of absenteeism or disciplinary actions.
11. Document current providers and supports, indicating the type of service or support and the date it began for each entry.
12. Identify the enrollee's strengths that will support the treatment process.
13. List goals that are behavior-based as indicated on the treatment or service plans. Include multiple goals for multiple requests.
14. Acknowledge any barriers or weaknesses that may affect treatment outcomes.
15. Outline a discharge plan to support a smooth transition upon completion of services.
16. After completing the form, review all entries for accuracy. Users can then save changes, download, print, or share the completed form as needed.

Take the next step towards accessing care by completing the Behavioral Health Outpatient Prior Authorization Form online today.