including coordination of access when clinically indicated. SIGNATURE OF STAFF COMPLETING THE FORM Name Signature/Credential: Date: PLEASE SEND FORM TO THE DESIGNATED HEALTHCARE PLAN USING THE CONTACT INFORMATION BELOW FOLLOWING THE TIME FRAME REQUIREMENTS IN THE ARTS PROVIDER MANUAL. Please note a processing time for ASAM Level 4.0/3.7/3.5/3.3 is 1 calendar day from receipt and ASAM Level 3.1/2.5/2.1 is 3 calendar days from receipt. CONTACT INFORMATION Medallion 3.0 Managed Care Organization Phone Number Fax Number Aetna Better Health (866) 669-2454 (804) 350-0816 (877) 434-7578 (for inpatient) Anthem Healthkeepers Plus (800) 901-0020 (800) 505-1193 (for outpatient) (888)393‐8978 INTotal Health (855) 323‐5588 (301) 625-6104 Kaiser (301) 625-6103 (855) 414-1703 (301) 625-6102 (800) 648-8420 (844) 366-3899 Optima Family Care (757) 837-4878 (757) 552-7174 (800) 727-7536 (toll –free) Virginia Premier Health Plan (877) 739-1365 (804) 819-5151 (local) Commonwealth Coordinated Care (CCC) Plus Phone Number Fax Number Aetna Better Health of Virginia (866) 669-2454 (804) 350-0816 (877) 434-7578 (for inpatient) Anthem HealthKeepers Plus (800)901-0020 (800) 505-1193 (for outpatient) (866) 210-1523 Magellan Complete Care of Virginia (800) 424-4524 (844) 839-4612 (888) 946-1168 Optima Health Community Care (757) 837-4703 (855) 368-1542 UnitedHealthcare (877) 843-4366 (888) 237-3997 Virginia Premier Health Plan (844) 513-4951
including coordination of access when clinically indicated. SIGNATURE OF STAFF COMPLETING THE FORM Name Signature/Credential: Date: PLEASE SEND FORM TO THE DESIGNATED HEALTHCARE PLAN USING THE CONTACT INFORMATION BELOW FOLLOWING THE TIME FRAME REQUIREMENTS IN THE ARTS PROVIDER MANUAL. Please note a processing time for ASAM Level 4.0/3.7/3.5/3.3 is 1 calendar day from receipt and ASAM Level 3.1/2.5/2.1 is 3 calendar days from receipt. CONTACT INFORMATION Medallion 3.0 Managed Care Organization Phone Number Fax Number Aetna Better Health (804) 350-0816 (866) 669-2454 Anthem Healthkeepers Plus (800) 901-0020 (877) 434-7578 (for inpatient) (800) 505-1193 (for outpatient) INTotal Health (855) 323‐5588 (888)393‐8978 Kaiser (301) 625-6104 (301) 625-6103 (301) 625-6102 (855) 414-1703 Optima Family Care (800) 648-8420 (757) 552-7174 (844) 366-3899 (757) 837-4878 Virginia Premier Health Plan (800) 727-7536 (toll –free) (804) 819-5151 (local) (877) 739-1365 Commonwealth Coordinated Care (CCC) Plus Phone Number Fax Number Aetna Better Health of Virginia (804) 350-0816 (866) 669-2454 Anthem HealthKeepers Plus (800)901-0020 (877) 434-7578 (for inpatient) (800) 505-1193 (for outpatient) Magellan Complete Care of Virginia (800) 424-4524 (866) 210-1523 Optima Health Community Care (888) 946-1168 (844) 839-4612 (757) 837-4703 UnitedHealthcare (877) 843-4366 (855) 368-1542 Virginia Premier Health Plan (844) 513-4951 (888) 237-3997
arts-extension-service-authorization-request-form-06062018-locked.docx