Get Appeal Request Form - Magellan Complete Care Of Virginia

If you do not agree with the decision made by Magellan Complete Care of Virginia regarding a service request or payment issue, you have the right to appeal. This guide provides clear, step-by-step instructions on how to complete the Appeal Request Form online.

Follow the steps to successfully complete the Appeal Request Form

1. Press the ‘Get Form’ button to access the form and open it in the document editor.
2. Begin by entering the member name in the designated field, ensuring it matches the name listed in your documentation.
3. In the member ID field, input the unique identification number assigned to you by Magellan Complete Care of Virginia.
4. Fill in the member date of birth, ensuring you use the correct format.
5. Provide the date of service related to the appeal, which is the date when the service in question was provided.
6. Enter the provider's name who delivered the service you are appealing.
7. Input your preferred contact phone number where you can be reached for further questions or clarifications.
8. List the service(s) being appealed, detailing the specific services for which you are challenging the decision.
9. Indicate whether you are requesting Continuation of Benefit by selecting ‘Yes’ or ‘No’. Note that the request must be made within the specified timeframe.
10. In the reason for appeal section, provide a detailed explanation of why you disagree with the decision. Be as clear and comprehensive as possible.
11. You may attach any additional information that supports your appeal. Ensure all documents are legible and organized.
12. Once you have completed the form, save your changes. You may then download, print, or share the completed form as needed.

Complete your appeal request form online today to ensure your voice is heard.