Provider Procedural Manual - The Health Plan

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PROVIDER PROCEDURAL MANUAL 2014Chart Stickers AvailableAdvance Directives, Health Plan, and Allergy chart stickers are available foruse by your office at no cost by calling the Provider Relations Department.St. Clairsville: (800) 624-6961 Extension 6248 or (740) 699-6248HomeTown: (877) 236-2289 Extension 2265 or (330) 834-2265These stickers are helpful in identifying your Health Plan patients, those withallergies, and if they have Advance Directives. They will also help your officemeet the requirements listed in our “Standards for Patient Record” Guideline.If you would like a copy of these guidelines, please call the Quality ImprovementDepartment at 1-800-624-6961, ext 7659 or 1-740-695-7659.Advance DirectivesHealth Plan PatientAllergyADVANCE DIRECTIVESOFFERED (DATE) ____________LIVING WILL yes ____ no __MEDICAL POWER OF ATTORNEY yes ____ no __HEALTH PLAN PATIENTLIST ALLERGIES:HEALTH PLANPATIENTNKA:Section 8 / Page 42
DILATED FUNDUS EXAMINATION(for the diabetic patient)PLACE MEMBERLABEL HEREPatient: DOB: HP ID#:Primary Physician: Gender: Exam Date:Date of Diabetes Diagnosis:Date of Last Ophthalmology/Optometry Exam:Visual Acuity: Right eye Left eye ________LABS: Recent glucose Date ___________________ HbA 1c Date ______________________EXAMINATION RESULTS RIGHT EYE LEFT EYE1) No diabetic retinopathy2) Background diabetic retinopathy3) Proliferative diabetic retinopathy4) Is clinically significant macular edema present? Yes No Yes No5) Are high risk characteristics present? Yes No Yes No6) Are there other worrisome findings present?If so, please specify in the space provided below.Yes No Yes No7) Is laser treatment indicated? Yes No Yes NoIf so, please specify type: Focal PRP Focal PRP8) Is other treatment indicated?If so, please specify in the space provided below.Yes No Yes NoRecommended follow-up date: _______________________________________________________________Other findings: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Other recommendations or comments:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Ophthalmologist/Optometrist Signature: ____________________________ Date: ___________________Ophthalmologist/Optometrist Name (Please print): _____________________________________________Report sent to Primary Care Physician (initial):Report sent to The Health Plan (initial):Diabetic Dilated Fundus Examination FormSection 8 / Page 43Date:Date:
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Volume2010 2014THE HEALTH PLANProvi
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Table of ContentsS E C T I O N 1INT
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S E C T I O N 7 C O N T I N U E DAP
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S E C T I O N 1 4PAYMENT VOUCHER ..
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PROVIDER PROCEDURAL MANUAL 2014INTR
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PROVIDER PROCEDURAL MANUAL 2013Sect
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HEALTH PLAN PRODUCT MATRIXSt. Clair
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The Health Plan of the Upper Ohio V
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WV PRENATAL RISK SCREENING INSTRUME
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THE HEALTH PLANPRE-AUTHORIZATION /
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The Health Plan Medical Management
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Standing ReferralsPROVIDER PROCEDUR
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Podiatric ServicesPROVIDER PROCEDUR
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Diabetes ProgramPROVIDER PROCEDURAL
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Chronic Heart FailurePROVIDER PROCE
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Prenatal Care ProgramPROVIDER PROCE
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Page 129 and 130: Physician VariancesPROVIDER PROCEDU
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Page 133 and 134: Health Plan Referral WorksheetTODAY
Page 135 and 136: THE HEALTH PLAN(Please Print)MEMBER
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Page 169 and 170: St. Clairsville Office52160 Nationa
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Page 175 and 176: 2 to 20 years: BoysBody mass index-
Page 177: Name: DOB: Date:Height:Weight:BMI P
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Page 203 and 204: NAME:DOB:PATIENT PHONE NUMBER:PHARM
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Page 207 and 208: Patient Name: _____________________
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Page 213 and 214: PREVENTIVE HEALTH FLOW SHEETADULTS
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InterQual® ReviewPROVIDER PROCEDUR
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Admission Chief Complaint:Precipita
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The Health Plan of the Upper Ohio V
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St. Clairsville OfficeBehavioral He
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Current Treatment/Services:Risk Lev
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St. Clairsville Office | 52160 Nati
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St. Clairsville OfficeBehavioral He
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St. Clairsville Office52160 Nationa
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CPT BILLED ALLOWED DISALLOWED COPAY
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8/4/2008Provider Name123 Wellness L
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PROVIDER PROCEDURAL MANUAL 2014***
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PROVIDER PROCEDURAL MANUAL 2014RESU
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CLAIM RESUBMISSION FORMPlease read
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JanuarySUN MON TUE WED THU FRI SAT1
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Provider Name:Revised: 05/99, 02/00
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STDNBRSTANDARDDOESNOTAPPLYMETNOTMET
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(Please Print)Provider Name:Special
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III. Laboratory Work performed in o
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BEHAVIORAL HEALTHProvider Name:Revi
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BEHAVIORAL HEALTHIII. Laboratory Wo
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The Health Plan Office OrientationO
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Section 15 / Page 24
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THE HEALTH PLANSTANDARDS FOR PATIEN
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PHYSICIAN:THE HEALTH PLAN - MEDICAL
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Provider Procedural Manual - The Health Plan

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