File a claim

This claim form should be submitted when a patient receives services from an out-of-network provider who requests the patient submit reimbursement to their own insurance company.

Your provider should give you a statement of services that contains the following items in order for Magellan to consider this claim as complete. You will file this claim by providing some personal identifying information and uploading your supporting document, including an itemized billing statement.

  Click here for a sample provider statement.

If you have questions about any of the following items, please call Magellan for assistance.

The statement of services should include the following items:

  • Employee ID number.
  • Policy holder's name.
  • Legal name of patient - must match the name on file with employer.
  • Patient's date of birth.
  • Patient's address - must match address on file with employer.
  • Date of service.
  • Type of service rendered - CPT code, Revenue code or verbal description.
  • Diagnosis - ICD-10 code.
  • Amount of charge - for each CPT code billed.
  • Name of provider with provider's degree, address and phone number.
  • Provider's tax identification number.
  • Provider's NPI identification number.

I understand that missing information may result in a delay to processing my claim.

Upload Statement/Invoice