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PROVIDER GRIEVANCE FORM

Directions: Use this form to communicate with Magellan of Virginia any grievance related to another Provider or Magellan. Please be as detailed as possible in your comments. The areas of the form notated with a red asterisk are required. The form cannot be submitted if those areas are blank.

Please use the “UPLOAD” or “Browse” button to attach any additional information that you believe is relevant to your grievance (e.g.: Claim Forms, Explanation of Benefit, Correspondence from Magellan, etc.).

COMPLAINTANT’S INFORMATION

Provider Name *

Provider MIS Number *

Provider Address *

Contact Name *

Contact Phone Number *

GRIEVANCE DETAILS

Who is the grievance about? *

Magellan
Another Provider
Other

Member Name (if the grievance involves a Member)

Member Medicaid ID Number

Date of Birth

Level of Care

What is the grievance about? (Please provide us with as many details as possible).

What would you like Magellan to do to resolve the grievance?

Do you consent to the use of your agency’s name as provided above during Magellan’s investigation? *

yes
no

Please upload any additional information that you believe is relevant to your grievance (e.g.: Claim Forms, Explanation of Benefit, Correspondence from Magellan, etc.).

Additional File

News & Publications

PROVIDER GRIEVANCE FORM

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