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Nebraska Appendix D: Forms and Processes

Effective Jan. 1, 2017, Magellan no longer manages behavioral health services for Nebraska Plan recipients. Refer to the below documents only as they relate to services provided on or before Dec. 31, 2016.

Abilify Maintena Injection Request (PDF) (updated 1/16)

Adjustment or Dispute for Claims Request Form (PDF)

Adult Substance Use Disorder Reauthorization (PDF)

Aristada Injection Request Form (PDF) (New 1/16)

Authorization Change Request- Medicaid (PDF)

Authorization to Use or Disclose Protected Health Information – Option 1 (PDF)

Authorization to Use or Disclose Protected Health Information – Option 2 (PDF)

Child-Adolescent Discharge Notification (PDF)

Clinical Appeals Workflow (PDF)

Community Treatment Aide Request (PDF)

Complaint and Grievance Process (PDF)

Critical Incident Definitions (PDF)

Critical Incident Report (PDF)

Designation of Authorized Representative (PDF) 

Electroconvulsive Therapy Request -- Initial (PDF)

Electroconvulsive Therapy Request -- Subsequent (PDF)

Invega Sustenna Injection Request (PDF) (updated 1/16)

Invega Trinza Injection Request (PDF) (updated 1/16)

MRO Reauthorization (PDF)

Member Rights and Responsibilities (PDF)

Professional Resource Family Care Application (PDF)

Psychiatric Residential Treatment Facility (PRTF) Prior Authorization Request (PDF)

Psychological Testing Request (PDF)

Risperdal Consta Injection Request (PDF)

Sex Offender Risk Assessment Request Form (PDF)

Therapeutic Group Home Application (PDF)

Therapeutic Leave Day Request (PDF)

Treatment Record Review Users Guide (PDF)

Vivitrol Injection Request (PDF) (updated 1/16)