Provider Procedural Manual - The Health Plan

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St. Clairsville Office52160 National Rd. EastSt. Clairsville, OH 43950Phone: 740.695.3585Toll Free: 800.624.6961SUN MON TUE WED THU FRI SAT1 2 3 41 2 3 4551212191926266613132020272777141421212828January88151522222929991616232330301010171724243131111118182525SUN MON TUE WED THU FRI SAT1 2 3 4 591 92 93 94 95696131032011027117797141042111128118898151052211229119April999161062311330120101001710724114111011810825115121021910926116SUN MON TUE WED THU FRI SAT1 2 3 4 5182 183 184 185 186618713194202012720871881419521202282098189151962220329210July919016197232043021110191171982420531212111921819925206121931920026207SUN MON TUE WED THU FRI SAT1 2 3 4274 275 276 277527812285192922629962791328620293273007280142872129428301October8281152882229529302928216289232963030310283172902429731304112841829125298SUN MON TUE WED THU FRI SAT13223394016472354334104117482455February43511421849255653612431950265763713442051275873814452152285983915462253SUN MON TUE WED THU FRI SAT1 2 3121 122 123412411131181382514551251213219139261466126131332014027147May71271413421141281488128151352214229149912916136231433015010130171372414431151SUN MON TUE WED THU FRI SAT1 2213 21432151022217229242363124342161122318230252375217122241923126238August6218132252023227239721914226212332824082201522722234292419221162282323530242SUN MON TUE WED THU FRI SAT13052306931316320233273033433071031417321243282014November43081131518322253295309123161932326330631013317203242733173111431821325283328312153192232629333SUN MON TUE WED THU FRI SAT1602619681675238230893621069177624833190463117018772584March564127119782685665137220792786766147321802887867157422812988SUN MON TUE WED THU FRI SAT1 2 3 4 5 6 7152 153 154 155 156 157 15881591516622173291809160161672317430181101611716824175June111621816925176121631917026177131642017127178141652117228179SUN MON TUE WED THU FRI SAT1 2 3 4 5 6244 245 246 247 248 24972501425721264282718251152582226529272September9252162592326630273102531726024267112541826125268122551926226269132562026327270SUN MON TUE WED THU FRI SAT1 2 3 4 5 6335 336 337 338 339 34073411434821355283628342153492235629363Massillon Office100 Lillian Gish Blvd.PO Box 4816Massillon, OH 44648Phone: 330.830.4370Toll Free: 888.830.4370December934316350233573036410344173512435831365113451835225359123461935326360133472035427361
St. Clairsville Office52160 National Rd. EastSt. Clairsville, OH 43950Phone: 740.695.3585Toll Free: 800.624.6961SUN MON TUE WED THU FRI SAT1 2 3 4 51 2 3 4 5661313202027277714142121282888151522222929January991616232330301010171724243131111118182525121219192626SUN MON TUE WED THU FRI SAT1 2 3 4 5 691 92 93 94 95 96797141042111128118898151052211229119999161062311330120April101001710724114111011810825115121021910926116131032011027117SUN MON TUE WED THU FRI SAT1 2 3 4 5 6182 183 184 185 186 187718814195212022820981891519622203292109190161972320430211July10191171982420531212111921819925206121931920026207131942020127208SUN MON TUE WED THU FRI SAT1 2 3 4 5274 275 276 277 278627913286202932730072801428721294283018281152882229529302October928216289232963030310283172902429731304112841829125298122851929226299SUN MON TUE WED THU FRI SAT1 232 33334104117482455435114218492556February5361243195026576371344205127587381445215228598391546225394016472354SUN MON TUE WED THU FRI SAT1 2 3 4121 122 123 124512512132191392614661261313320140271477127141342114128148May8128151352214229149912916136231433015010130171372414431151111311813825145SUN MON TUE WED THU FRI SAT1 2 3213 214 215421611223182302523752171222419231262386218132252023227239August72191422621233282408220152272223429241922116228232353024210222172292423631243SUN MON TUE WED THU FRI SAT1 2305 306330710314173212432843081131518322253292013November53091231619323263306310133172032427331731114318213252833283121531922326293339313163202332730334SUN MON TUE WED THU FRI SAT1 260 613621069177624833190463117018772584564127119782685March665137220792786766147321802887867157422812988968167523823089SUN MON TUE WED THU FRI SAT11522153916016167231743018131541016117168241754155111621816925176June5156121631917026177615713164201712717871581416521172281798159151662217329180SUN MON TUE WED THU FRI SAT1 2 3 4 5 6 7244 245 246 247 248 249 25082511525822265292729252162592326630273September102531726024267112541826125268122551926226269132562026327270142572126428271SUN MON TUE WED THU FRI SAT1 2 3 4 5 6 7335 336 337 338 339 340 34183421534922356293639343163502335730364Massillon Office100 Lillian Gish Blvd.PO Box 4816Massillon, OH 44648Phone: 330.830.4370Toll Free: 888.830.4370December10344173512435831365113451835225359123461935326360133472035427361143482135528362
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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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Section 2 / Page 3
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Section 2 / Page 5
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PROVIDER PROCEDURAL MANUAL 2014f. I
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PROVIDER PROCEDURAL MANUAL 2014f. I
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HEALTH PLAN PRODUCT MATRIXSt. Clair
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PROVIDER PROCEDURAL MANUAL 2014HEAL
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PROVIDER PROCEDURAL MANUAL 2014It i
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PROVIDER PROCEDURAL MANUAL 2014SECU
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PROVIDER PROCEDURAL MANUAL 2014APPO
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PROVIDER PROCEDURAL MANUAL 2014PROV
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PROVIDER PROCEDURAL MANUAL 2014APPO
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PROVIDER PROCEDURAL MANUAL 2014THP
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PROVIDER PROCEDURAL MANUAL 2014THP
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PROVIDER PROCEDURAL MANUAL 2014Excl
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PROVIDER PROCEDURAL MANUAL 2014III.
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PROVIDER PROCEDURAL MANUAL 2014PAGE
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PROVIDER PROCEDURAL MANUAL 2014The
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PROVIDER PROCEDURAL MANUAL 2014Secu
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PROVIDER PROCEDURAL MANUAL 2014THE
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PROVIDER PROCEDURAL MANUAL 2014Medi
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PROVIDER PROCEDURAL MANUAL 2014Stan
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PROVIDER PROCEDURAL MANUAL 2014Requ
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PROVIDER PROCEDURAL MANUAL 2014Bill
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PROVIDER PROCEDURAL MANUAL 2014PRES
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The Health Plan of the Upper Ohio V
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PROVIDER PROCEDURAL MANUAL 2014Heal
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PROVIDER PROCEDURAL MANUAL 2014FAMI
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PROVIDER PROCEDURAL MANUAL 2014SURG
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WV PRENATAL RISK SCREENING INSTRUME
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PROVIDER PROCEDURAL MANUAL 2014SMOK
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PROVIDER PROCEDURAL MANUAL 2014Your
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PROVIDER PROCEDURAL MANUAL 2014OFFI
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PROVIDER PROCEDURAL MANUAL 2014Dedu
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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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Physician VariancesPROVIDER PROCEDU
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PROVIDER PROCEDURAL MANUAL 2014Appe
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Health Plan Referral WorksheetTODAY
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THE HEALTH PLAN(Please Print)MEMBER
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PROVIDER PROCEDURAL MANUAL 2014Qual
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PROVIDER PROCEDURAL MANUAL 2014Qual
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QI Variance ProcessPROVIDER PROCEDU
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PROVIDER PROCEDURAL MANUAL 2014*Sta
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PROVIDER PROCEDURAL MANUAL 2014Prov
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2013-2014QI Information SheetDear P
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Advance DirectivesFlow ChartName: _
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PROVIDER PROCEDURAL MANUAL 2014Anti
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St. Clairsville Office52160 Nationa
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PROVIDER PROCEDURAL MANUAL 2014Body
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BODY MASS INDEX (BMI)PATIENT NAME:
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2 to 20 years: BoysBody mass index-
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Name: DOB: Date:Height:Weight:BMI P
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DILATED FUNDUS EXAMINATION(for the
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THE HEALTH PLAN OF THE UPPER OHIO V
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PROVIDER PROCEDURAL MANUAL 2014Faxi
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Code Measure Title LOBs Description
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Immunization RegistryPROVIDER PROCE
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NAME:DOB:PATIENT PHONE NUMBER:PHARM
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PROVIDER PROCEDURAL MANUAL 2014ONSI
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Patient Name: _____________________
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Prescription Drug AbusePROVIDER PRO
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PREVENTIVE HEALTH FLOW SHEETADULTS
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Signature LogLegible Name( Print /
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Vaccine Administration Recordfor Ch
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PROVIDER PROCEDURAL MANUAL 2014Beha
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Specialty PharmacyTo preauthorize S
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PROVIDER PROCEDURAL MANUAL 2014Pre-
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InterQual® ReviewPROVIDER PROCEDUR
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PROVIDER PROCEDURAL MANUAL 2014Beha
Page 233 and 234: PROVIDER PROCEDURAL MANUAL 2014Beha
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 and 254: St. Clairsville Office52160 Nationa
Page 255 and 256: St. Clairsville Office | 52160 Nati
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
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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: CLAIM RESUBMISSION FORMPlease read
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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: PROVIDER PROCEDURAL MANUAL 2014Sect
Page 325 and 326: PROVIDER PROCEDURAL MANUAL 2014HEAL
Page 327: PROVIDER PROCEDURAL MANUAL 2014HEAL
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Provider Procedural Manual - The Health Plan

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