Provider Procedural Manual - The Health Plan

More documents

Recommendations

Info

INFORMATION CONTINUED for Member:What are the CURRENT symptoms the client is exhibiting?How will the results of the testing affect the treatment plan?What treatment(s) has/have already been rendered to the client?REQUESTED TESTING:TEST NAME/CPT CODE1)TEST TYPE2)3)4)Are there any factors that could affect the outcome of the test (i.e. substance abuse, illiterate)?Provider SignatureRequest Date
St. Clairsville Office | 52160 National Road East, St. Clairsville, OH 43950-9365 | Local PH: 1.740.695.7896HomeTown Office | 100 Lillian Gish Boulevard, P.O. Box 4816 | Massillon, OH 44648-4816 | Local PH: 1.330.834.2354www.healthplan.orgPlease fax to: Behavioral Health Unit: 740.699.6255 • Toll Free: 1.866.616.6255TREATMENT CONTINUATION REQUEST FORMBehavioral Health Unit* All Sections must be completed for timely approvalPatient Name:Member I.D. #:Date of Birth:Provider Name:Phone Number: NPI #:Address:Date of Evaluation Visit for current Episode of Care:DSM IV Multi-Axial Diagnosis (Complete all 5 Axis)Axis 1Axis 2Axis 3Axis 4Axis 5Diagnosis Code:Diagnosis Code:Does the patient have a current medical condition linked to the Axis 1 or 2 diagnosis?Please describe below:Describe Axis 3:Please indicate the Severity of Current Psych Social Stressors:GAF Score: Highest Past Year: Current:YesNoNone Mild Moderate SevereCurrent Medications:Anti-PyschoticHypnoticPsycho-StimulantAnti-AnxietyMood StabilizerOther/Commets:Anti-DepressantMedicalNoneRisk Assessment: Ideation Plan IntentSuicidal IdeationHomicidal IdeationNoneSymptoms: (if present, check degree)Mild Moderate Severe Mild Moderate SevereDepressed MoodAnhedoniaLow EnergyAnxietyPanic AttacksInattentionHopelessnessImpulsiveSomatoform/Bingeing/PurgingFictitious ProblemsRestricting Food IntakeSocial IsolationSelf MutilationSleep DisturbanceMood SwingsHyperactiveHallucinationDelusionsOther Psychotic SymptomsObsessions/CompulsionsNo Symptoms
Page 1 and 2:
Volume2010 2014THE HEALTH PLANProvi
Page 3 and 4:
Table of ContentsS E C T I O N 1INT
Page 5 and 6:
S E C T I O N 7 C O N T I N U E DAP
Page 7 and 8:
S E C T I O N 1 4PAYMENT VOUCHER ..
Page 9 and 10:
PROVIDER PROCEDURAL MANUAL 2014INTR
Page 11 and 12:
PROVIDER PROCEDURAL MANUAL 2013Sect
Page 13 and 14:
Section 2 / Page 3
Page 15 and 16:
Section 2 / Page 5
Page 17 and 18:
PROVIDER PROCEDURAL MANUAL 2014f. I
Page 19 and 20:
PROVIDER PROCEDURAL MANUAL 2014f. I
Page 21 and 22:
Page 23 and 24:
HEALTH PLAN PRODUCT MATRIXSt. Clair
Page 25 and 26:
PROVIDER PROCEDURAL MANUAL 2014HEAL
Page 27 and 28:
PROVIDER PROCEDURAL MANUAL 2014It i
Page 29 and 30:
PROVIDER PROCEDURAL MANUAL 2014SECU
Page 31 and 32:
PROVIDER PROCEDURAL MANUAL 2014APPO
Page 33 and 34:
PROVIDER PROCEDURAL MANUAL 2014PROV
Page 35 and 36:
PROVIDER PROCEDURAL MANUAL 2014APPO
Page 37 and 38:
PROVIDER PROCEDURAL MANUAL 2014THP
Page 39 and 40:
Page 41 and 42:
PROVIDER PROCEDURAL MANUAL 2014THP
Page 43 and 44:
PROVIDER PROCEDURAL MANUAL 2014Excl
Page 45 and 46:
PROVIDER PROCEDURAL MANUAL 2014III.
Page 47 and 48:
PROVIDER PROCEDURAL MANUAL 2014PAGE
Page 49 and 50:
PROVIDER PROCEDURAL MANUAL 2014The
Page 51 and 52:
PROVIDER PROCEDURAL MANUAL 2014Secu
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
PROVIDER PROCEDURAL MANUAL 2014THE
Page 59 and 60:
PROVIDER PROCEDURAL MANUAL 2014Medi
Page 61 and 62:
PROVIDER PROCEDURAL MANUAL 2014Stan
Page 63 and 64:
PROVIDER PROCEDURAL MANUAL 2014Requ
Page 65 and 66:
PROVIDER PROCEDURAL MANUAL 2014Bill
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
PROVIDER PROCEDURAL MANUAL 2014PRES
Page 73 and 74:
The Health Plan of the Upper Ohio V
Page 75 and 76:
PROVIDER PROCEDURAL MANUAL 2014Heal
Page 77 and 78:
PROVIDER PROCEDURAL MANUAL 2014FAMI
Page 79 and 80:
PROVIDER PROCEDURAL MANUAL 2014SURG
Page 81 and 82:
WV PRENATAL RISK SCREENING INSTRUME
Page 83 and 84:
PROVIDER PROCEDURAL MANUAL 2014SMOK
Page 85 and 86:
Page 87 and 88:
Page 89 and 90:
PROVIDER PROCEDURAL MANUAL 2014Your
Page 91 and 92:
PROVIDER PROCEDURAL MANUAL 2014OFFI
Page 93 and 94:
PROVIDER PROCEDURAL MANUAL 2014Dedu
Page 95 and 96:
Page 97 and 98:
THE HEALTH PLANPRE-AUTHORIZATION /
Page 99 and 100:
The Health Plan Medical Management
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
Standing ReferralsPROVIDER PROCEDUR
Page 107 and 108:
Podiatric ServicesPROVIDER PROCEDUR
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
Page 117 and 118:
Diabetes ProgramPROVIDER PROCEDURAL
Page 119 and 120:
Chronic Heart FailurePROVIDER PROCE
Page 121 and 122:
Page 123 and 124:
Prenatal Care ProgramPROVIDER PROCE
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Physician VariancesPROVIDER PROCEDU
Page 131 and 132:
PROVIDER PROCEDURAL MANUAL 2014Appe
Page 133 and 134:
Health Plan Referral WorksheetTODAY
Page 135 and 136:
THE HEALTH PLAN(Please Print)MEMBER
Page 137 and 138:
PROVIDER PROCEDURAL MANUAL 2014Qual
Page 139 and 140:
Page 141 and 142:
PROVIDER PROCEDURAL MANUAL 2014Qual
Page 143 and 144:
Page 145 and 146:
QI Variance ProcessPROVIDER PROCEDU
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
PROVIDER PROCEDURAL MANUAL 2014*Sta
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
PROVIDER PROCEDURAL MANUAL 2014Prov
Page 161 and 162:
2013-2014QI Information SheetDear P
Page 163 and 164:
Page 165 and 166:
Advance DirectivesFlow ChartName: _
Page 167 and 168:
PROVIDER PROCEDURAL MANUAL 2014Anti
Page 169 and 170:
St. Clairsville Office52160 Nationa
Page 171 and 172:
PROVIDER PROCEDURAL MANUAL 2014Body
Page 173 and 174:
BODY MASS INDEX (BMI)PATIENT NAME:
Page 175 and 176:
2 to 20 years: BoysBody mass index-
Page 177 and 178:
Name: DOB: Date:Height:Weight:BMI P
Page 179 and 180:
DILATED FUNDUS EXAMINATION(for the
Page 181 and 182:
Page 183 and 184:
THE HEALTH PLAN OF THE UPPER OHIO V
Page 185 and 186:
PROVIDER PROCEDURAL MANUAL 2014Faxi
Page 187 and 188:
Code Measure Title LOBs Description
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
Page 199 and 200:
Page 201 and 202:
Immunization RegistryPROVIDER PROCE
Page 203 and 204: NAME:DOB:PATIENT PHONE NUMBER:PHARM
Page 205 and 206: PROVIDER PROCEDURAL MANUAL 2014ONSI
Page 207 and 208: Patient Name: _____________________
Page 209 and 210: PROVIDER PROCEDURAL MANUAL 2014The
Page 211 and 212: Prescription Drug AbusePROVIDER PRO
Page 213 and 214: PREVENTIVE HEALTH FLOW SHEETADULTS
Page 215 and 216: Signature LogLegible Name( Print /
Page 217 and 218: Vaccine Administration Recordfor Ch
Page 221 and 222: PROVIDER PROCEDURAL MANUAL 2014Sect
Page 223 and 224: PROVIDER PROCEDURAL MANUAL 2014Beha
Page 225 and 226: Specialty PharmacyTo preauthorize S
Page 227 and 228: PROVIDER PROCEDURAL MANUAL 2014Pre-
Page 229 and 230: InterQual® ReviewPROVIDER PROCEDUR
Page 235 and 236: PROVIDER PROCEDURAL MANUAL 2014Depr
Page 241 and 242: Admission Chief Complaint:Precipita
Page 243 and 244: The Health Plan of the Upper Ohio V
Page 245 and 246: St. Clairsville OfficeBehavioral He
Page 247 and 248: Current Treatment/Services:Risk Lev
Page 249 and 250: St. Clairsville Office | 52160 Nati
Page 251 and 252: St. Clairsville OfficeBehavioral He
Page 253: St. Clairsville Office52160 Nationa
Page 257 and 258: PROVIDER PROCEDURAL MANUAL 2014Plea
Page 259 and 260: PROVIDER PROCEDURAL MANUAL 2014BILL
Page 261 and 262: PROVIDER PROCEDURAL MANUAL 2014BILL
Page 263 and 264: PROVIDER PROCEDURAL MANUAL 2014Elec
Page 265 and 266: PROVIDER PROCEDURAL MANUAL 2014COOR
Page 267 and 268: PROVIDER PROCEDURAL MANUAL 2014Plea
Page 269 and 270: CPT BILLED ALLOWED DISALLOWED COPAY
Page 271 and 272: PROVIDER PROCEDURAL MANUAL 2014HELP
Page 275 and 276: PROVIDER PROCEDURAL MANUAL 2014CLAI
Page 277 and 278: 8/4/2008Provider Name123 Wellness L
Page 279 and 280: PROVIDER PROCEDURAL MANUAL 2014***
Page 281 and 282: PROVIDER PROCEDURAL MANUAL 2014RESU
Page 283 and 284: CLAIM RESUBMISSION FORMPlease read
Page 285 and 286: St. Clairsville Office52160 Nationa
Page 287 and 288: St. Clairsville Office52160 Nationa
Page 289 and 290: JanuarySUN MON TUE WED THU FRI SAT1
Page 291 and 292: PROVIDER PROCEDURAL MANUAL 2014CRED
Page 293 and 294: PROVIDER PROCEDURAL MANUAL 2014STAN
Page 295 and 296: Provider Name:Revised: 05/99, 02/00
Page 297 and 298: STDNBRSTANDARDDOESNOTAPPLYMETNOTMET
Page 299 and 300: (Please Print)Provider Name:Special
Page 301 and 302: III. Laboratory Work performed in o
Page 303 and 304: BEHAVIORAL HEALTHProvider Name:Revi
Page 305 and 306:
BEHAVIORAL HEALTHSTDNBRSTANDARDDOES
Page 307 and 308:
BEHAVIORAL HEALTHProvider Name:(Ple
Page 309 and 310:
BEHAVIORAL HEALTHIII. Laboratory Wo
Page 311 and 312:
The Health Plan Office OrientationO
Page 313 and 314:
Section 15 / Page 24
Page 315 and 316:
THE HEALTH PLANSTANDARDS FOR PATIEN
Page 317 and 318:
PHYSICIAN:THE HEALTH PLAN - MEDICAL
Page 319 and 320:
PROVIDER PROCEDURAL MANUAL 2014SIGN
Page 321 and 322:
PROVIDER PROCEDURAL MANUAL 2014TELE
Page 323 and 324:
Page 325 and 326:
Page 327:
show all

Provider Procedural Manual - The Health Plan

Create successful ePaper yourself

Delete template?

Save as template?