Reconsideration of Qualified Evaluator (QE) Recommendation District/ SPOA Information: Child Information NAME: DOB: MEDICAID Type of Request CLARIFICATION OF OF RECOMMENDATION Please Fully Complete All Questions Below 1. 2. QE: 3. BY QE: 4. SPOA 5. What is the reason for this request (please explain in detail): 6. If a reconsideration of the QE recommendation is being requested, please explain, in detail, what attempts were made to stabilize the child/youth at the recommended level of care: 7. Additional comments for consideration: BELOW SECTION TO BE COMPLETED MAGELLAN ADMINISTRATION ONLY APPROVED COURT ORDERED Initials Comments
Reconsideration of Qualified Evaluator (QE) Recommendation District/ SPOA Information: Child Information NAME: DOB: Type of Request OF CLARIFICATION OF RECOMMENDATION Please Fully Complete All Questions Below 1. 2. QE: 3. QE: 4. SPOA 5. What is the reason for this request (please explain in detail): 6. If a reconsideration of the QE recommendation is being requested, please explain, in detail, what attempts were made to stabilize the child/youth at the recommended level of care: 7. Additional comments for consideration: BELOW SECTION TO BE COMPLETED BY MAGELLAN MEDICAID ADMINISTRATION ONLY APPROVED COURT ORDERED Initials Comments
QEN%20Request%20for%20Reconsideration%20Form.docx