Copy of Pre-Treatment

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Pre-Treatment Notification Form

Person Completing This Form:*

Request Type

I understand the urgent criteria has been met. wanting it quickly is not an Urgent request.*

Member Profile

Member ID#*

Name of Member*

Name of Patient*

Patient's Date of Birth*

Provider Profile

Physician's Network

Tin # For Physician

Name of Physician*

Physician's Office

Physician's Contact Person

Physician's E-Mail

Physician's Phone*

Contact Fax*

Facility's Network

Tin # For Treatment Facility

Name of Facility*

Facility Contact Person

Facility Phone

Facility Fax

Diagnosis or Chief Complaint Description*

Initial Date of Diagnosis(es) (If Available)

Diagnosis Code (If Available)

Procedure Description*

Procedure Code (If Available)

Has This Procedure Been:* Scheduled Unscheduled

Utilization Review Department Contact

Utilization Review Phone

Utilization Review Department Fax

Is This Hospital Stay Due to a Newborn Delivery?* Yes No

What Type of Deliver?* Vaginal Cesarean

Estimated Length of Stay*

TARGETFIELD

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Pre-Treatment Notification Form Summary

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Inpatient Clinical Evaluation Documentation: (Required To Complete Submission) Attach documentation file now
I will fax the documentation to (269) 349-3275

Attach Clinical Information

Summary

Person Completing This Form:

Employee/Patient Summary

Member ID#: Member Name: Patient Name: Patient's D.O.B.: Phone No.: E-Mail Address:

Provider Summary

Physician Name Physician Office Physician Phone Physician Fax Facility Name Facility Contact Person Facility Phone Facility Fax

Medical Information Summary

Diagnosis(es) or Symptoms Treatment Description Event Type Scheduled or Unscheduled? Date of Service Contact Person Procedure Code

Extra Information

Estimated Length of Stay Copy of Therapy Initial Evaluation and Plan Attach File Copy of Physician's Therapy Prescription Attach Perscription File Copy of Initial Evaluation and Plan Attach Inpatient File Initial Date of Diagnosis(es) Additional Clinical Information

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Status

status Details

M N

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Reference Number:

Your Pre-Treatment Notification form has been successfully submitted for review.
Once the review process has been completed, the appropriate healthcare provider will be notified.

Please Note: This process is not an approval or denial of coverage by the plan for this procedure. This process is not a guarantee of plan payment nor is it a determination of eligibility. This process is a review of the indicated treatment to determine if the procedure is appropriate for the diagnosis or condition noted. Coverage determinations are made once a claim has been submitted for payment. All benefits are subject to eligibility requirements, plan exclusions, exception and limitations at time of claim. If coverage terminates for any reason this review will be null and void.

If you have any questions regarding this process please contact us as (800) 238-1602.