MOLINA HEALTHCARE OF NEW MEXICO, INC. PROVIDER RECONSIDERATION REVIEW REQUEST (PRR) FORM

Transcription

1 MOLIN HELTHRE OF NEW MEXIO, IN. PROVIDER REONSIDERTION REVIEW REQUEST (PRR) FORM Plese print or type the following informtion: Prctitioner/Provider Nme: / TIN: Requestor nme nd title (if different thn ove): ddress: /Telephone: ( ) Memer Nme: Memer ID#/SS#: Dte of irth: / / SPEIFI REQUEST: RESON FOR REQUEST Procedure ode(s) in Question: illed mount of Procedure: Dte of Service: $ / / $ / / TTH OPIES OF THE FOLLOWING DOUMENTS, S PPLILE: ontrct informtion. The originl clim(s). If you originlly sumitted the clim electroniclly, hrd copy of the clim (s) in question will e needed. Explntion of enefits form(s). orrespondence nd/or chronology of pertinent events. Medicl records/progress notes nd/or opertive report to support request. Instructions. Print nd fill out this form completely, use reverse side if dditionl spce is needed. Descrie the issue in s much detil s possile nd ttch copies of the supporting documenttion s pplicle.. Include telephone numer tht you cn e reched t during usiness hours.. Return the completed form, within one hundred eighty (80) clendr dys of Molin Helthcre s notice of ction with your supporting documenttion ttched, to the ddress listed elow.. The PRR review will e completed within thirty (0) dys from the dte the request is received. / / Requestor Nme / Title (if different thn provider nme) Dte Telephone Numer Mil this form with documenttion to: Molin Helthcre of New Mexico, Inc. ttn: Network Mngment nd Opertions Deprtment - PRR Request PO ox 887, luquerque, NM Telephone Slud: luquerque (0) -79 or toll-free (888) 8-9 Telephone SI & UNM SI: luquerque (0) 8-78 or toll-free (8) 0-08 SR PRR Form Revised Dte: 0/0/0 Revised: 0/8/07, 9//09, /9/

2 00 HELTH INSURNE LIM FORM PPROVED Y NTIONL UNIFORM LIM OMMITTEE 08/0 PI PI RRIER. MEDIRE MEDIID TRIRE HMPV GROUP FE OTHER. INSURED S I.D. NUMER (For Progrm in Item ) HMPUS HELTH PLN LK LUNG (Medicre #) (Medicid #) (Sponsor s SSN) (Memer ID#) (SSN or ID) (SSN) (ID). PTIENT S NME (Lst Nme, First Nme, Middle Initil). PTIENT S IRTH DTE M F. INSURED S NME (Lst Nme, First Nme, Middle Initil). PTIENT S DDRESS (No., Street). PTIENT RELTIONSHIP TO INSURED 7. INSURED S DDRESS (No., Street) Self Spouse hild Other ITY STTE ZIP ODE TELEPHONE (Include re ode) 9. OTHER INSURED S NME (Lst Nme, First Nme, Middle Initil). OTHER INSURED S POLIY OR GROUP NUMER. OTHER INSURED S DTE OF IRTH M F c. EMPLOYER S NME OR SHOOL NME d. INSURNE PLN NME OR PROGRM NME 8. PTIENT STTUS Single Mrried Other Full-Time Prt-Time Employed Student Student 0. IS PTIENT S ONDITION RELTED TO:. EMPLOYMENT? (urrent or Previous). UTO IDENT? PLE (Stte) c. OTHER IDENT? 0d. RESERVED FOR LOL USE ITY STTE ZIP ODE TELEPHONE (Include re ode). INSURED S POLIY GROUP OR FE NUMER. INSURED S DTE OF IRTH M F. EMPLOYER S NME OR SHOOL NME c. INSURNE PLN NME OR PROGRM NME d. IS THERE THER HELTH ENEFIT PLN? PTIENT ND INSURED INFORMTION RED K OF FORM EFORE OMPLETING & SIGNING THIS FORM.. PTIENT S OR UTHORIZED PERSON S SIGNTURE I uthorize the relese of ny medicl or other informtion necessry to process this clim. I lso request pyment of government enefits either to myself or to the prty who ccepts ssignment elow. SIGNED DTE. DTE OF URRENT: 9. RESERVED FOR LOL USE ILLNESS (First symptom) OR INJURY (ccident) OR PREGNNY(LMP) 7. NME OF REFERRING PROVIDER OR OTHER SOURE 7.. IF PTIENT HS HD SME OR SIMILR ILLNESS. GIVE FIRST DTE. DIGSIS OR NTURE OF ILLNESS OR INJURY (Relte Items,, or to Item E y Line) INSURED S OR UTHORIZED PERSON S SIGNTURE I uthorize pyment of medicl enefits to the undersigned physicin or supplier for services descried elow. SIGNED If yes, return to nd complete item 9 -d.. DTES PTIENT UNLE TO WORK IN URRENT OUPTION TO 8. HOSPITLIZTION DTES RELTED TO URRENT SERVIES TO 0. OUTSIDE L? $ HRGES. MEDIID RESUMISSION ODE ORIGINL REF... PRIOR UTHORIZTION NUMER.... DTE(S) OF SERVIE.. D. PROEDURES, SERVIES, OR SUPPLIES E. From To PLE OF (Explin Unusul ircumstnces) DIGSIS SERVIE EMG PT/HPS MODIFIER POINTER. FEDERL TX I.D. NUMER SSN EIN. PTIENT S OUNT. 7. EPT SSIGNMENT? (For govt. clims, see ck). SIGNTURE OF PHYSIIN OR SUPPLIER INLUDING DEGREES OR REDENTILS (I certify tht the sttements on the reverse pply to this ill nd re mde prt thereof.) F. G. H. I. J. DYS EPSDT OR Fmily ID. RENDERING $ HRGES UNITS Pln QUL. PROVIDER ID. # 8. TOTL HRGE 9. MOUNT PID 0. LNE DUE $ $ $. SERVIE FILITY LOTION INFORMTION. ILLING PROVIDER INFO & PH # PHYSIIN OR SUPPLIER INFORMTION.... SIGNED DTE NU Instruction Mnul ville t: PPROVED OM FORM MS-00 (08-0)

3 EUSE THIS FORM IS USED Y VRIOUS GOVERNMENT ND PRIVTE HELTH PROGRMS, SEE SEPRTE INSTRUTIONS ISSUED Y PPLILE PROGRMS. TIE: ny person who knowingly files sttement of clim contining ny misrepresenttion or ny flse, incomplete or misleding informtion my e guilty of criminl ct punishle under lw nd my e suject to civil penlties. REFERS TO GOVERNMENT PROGRMS ONLY MEDIRE ND HMPUS PYMENTS: ptient s signture requests tht pyment e mde nd uthorizes relese of ny informtion necessry to process the clim nd certifies tht the informtion provided in locks through is true, ccurte nd complete. In the cse of Medicre clim, the ptient s signture uthorizes ny entity to relese to Medicre medicl nd nonmedicl informtion, including employment sttus, nd whether the person hs employer group helth insurnce, liility, no-fult, worker s compenstion or other insurnce which is responsile to py for the services for which the Medicre clim is mde. See FR.(). If item 9 is completed, the ptient s signture uthorizes relese of the informtion to the helth pln or gency shown. In Medicre ssigned or HMPUS prticiption cses, the physicin grees to ccept the chrge determintion of the Medicre crrier or HMPUS fiscl intermediry s the full chrge, nd the ptient is responsile only for the deductile, coinsurnce nd noncovered services. oinsurnce nd the deductile re sed upon the chrge determintion of the Medicre crrier or HMPUS fiscl intermediry if this is less thn the chrge sumitted. HMPUS is not helth insurnce progrm ut mkes pyment for helth enefits provided through certin ffilitions with the Uniformed Services. Informtion on the ptient s sponsor should e provided in those items cptioned in Insured ; i.e., items,,, 7, 9, nd. LK LUNG ND FE LIMS The provider grees to ccept the mount pid y the Government s pyment in full. See lck Lung nd FE instructions regrding required procedure nd dignosis coding systems. SIGNTURE OF PHYSIIN OR SUPPLIER (MEDIRE, HMPUS, FE ND LK LUNG) I certify tht the services shown on this form were mediclly indicted nd necessry for the helth of the ptient nd were personlly furnished y me or were furnished incident to my professionl service y my employee under my immedite personl supervision, except s otherwise expressly permitted y Medicre or HMPUS regultions. For services to e considered s incident to physicin s professionl service, ) they must e rendered under the physicin s immedite personl supervision y his/her employee, ) they must e n integrl, lthough incidentl prt of covered physicin s service, ) they must e of kinds commonly furnished in physicin s offices, nd ) the services of nonphysicins must e included on the physicin s ills. For HMPUS clims, I further certify tht I (or ny employee) who rendered services m not n ctive duty memer of the Uniformed Services or civilin employee of the United Sttes Government or contrct employee of the United Sttes Government, either civilin or militry (refer to US ). For lck-lung clims, I further certify tht the services performed were for lck Lung-relted disorder. No Prt Medicre enefits my e pid unless this form is received s required y existing lw nd regultions ( FR.). TIE: ny one who misrepresents or flsifies essentil informtion to receive pyment from Federl funds requested y this form my upon conviction e suject to fine nd imprisonment under pplicle Federl lws. TIE TO PTIENT OUT THE OLLETION ND USE OF MEDIRE, HMPUS, FE, ND LK LUNG INFORMTION (PRIVY T STTEMENT) We re uthorized y MS, HMPUS nd OWP to sk you for informtion needed in the dministrtion of the Medicre, HMPUS, FE, nd lck Lung progrms. uthority to collect informtion is in section 0(), 8, 87 nd 87 of the Socil Security ct s mended, FR.() nd.() (), nd US 0; FR 0 et seq nd 0 US 079 nd 08; US 80 et seq; nd 0 US 90 et seq; 8 US ; E.O The informtion we otin to complete clims under these progrms is used to identify you nd to determine your eligiility. It is lso used to decide if the services nd supplies you received re covered y these progrms nd to insure tht proper pyment is mde. The informtion my lso e given to other providers of services, crriers, intermediries, medicl review ords, helth plns, nd other orgniztions or Federl gencies, for the effective dministrtion of Federl provisions tht require other third prties pyers to py primry to Federl progrm, nd s otherwise necessry to dminister these progrms. For exmple, it my e necessry to disclose informtion out the enefits you hve used to hospitl or doctor. dditionl disclosures re mde through routine uses for informtion contined in systems of records. FOR MEDIRE LIMS: See the notice modifying system No , titled, rrier Medicre lims Record, pulished in the Federl Register, Vol. No. 77, pge 79, Wed. Sept., 990, or s updted nd repulished. FOR OWP LIMS: Deprtment of Lor, Privcy ct of 97, Repuliction of Notice of Systems of Records, Federl Register Vol. No. 0, Wed Fe. 8, 990, See ES-, ES-, ES-, ES-, ES-0, or s updted nd repulished. FOR HMPUS LIMS: PRINIPLE PURPOSE(S): To evlute eligiility for medicl cre provided y civilin sources nd to issue pyment upon estlishment of eligiility nd determintion tht the services/supplies received re uthorized y lw. ROUTINE USE(S): Informtion from clims nd relted documents my e given to the Dept. of Veterns ffirs, the Dept. of Helth nd Humn Services nd/or the Dept. of Trnsporttion consistent with their sttutory dministrtive responsiilities under HMPUS/HMPV; to the Dept. of Justice for representtion of the Secretry of Defense in civil ctions; to the Internl Revenue Service, privte collection gencies, nd consumer reporting gencies in connection with recoupment clims; nd to ongressionl Offices in response to inquiries mde t the request of the person to whom record pertins. pproprite disclosures my e mde to other federl, stte, locl, foreign government gencies, privte usiness entities, nd individul providers of cre, on mtters relting to entitlement, clims djudiction, frud, progrm use, utiliztion review, qulity ssurnce, peer review, progrm integrity, third-prty liility, coordintion of enefits, nd civil nd criminl litigtion relted to the opertion of HMPUS. DISLOSURES: Voluntry; however, filure to provide informtion will result in dely in pyment or my result in denil of clim. With the one exception discussed elow, there re no penlties under these progrms for refusing to supply informtion. However, filure to furnish informtion regrding the medicl services rendered or the mount chrged would prevent pyment of clims under these progrms. Filure to furnish ny other informtion, such s nme or clim numer, would dely pyment of the clim. Filure to provide medicl informtion under FE could e deemed n ostruction. It is mndtory tht you tell us if you know tht nother prty is responsile for pying for your tretment. Section 8 of the Socil Security ct nd US 80-8 provide penlties for withholding this informtion. You should e wre tht P.L. 00-0, the omputer Mtching nd Privcy Protection ct of 988, permits the government to verify informtion y wy of computer mtches. MEDIID PYMENTS (PROVIDER ERTIFITION) I herey gree to keep such records s re necessry to disclose fully the extent of services provided to individuls under the Stte s Title XIX pln nd to furnish informtion regrding ny pyments climed for providing such services s the Stte gency or Dept. of Helth nd Humn Services my request. I further gree to ccept, s pyment in full, the mount pid y the Medicid progrm for those clims sumitted for pyment under tht progrm, with the exception of uthorized deductile, coinsurnce, co-pyment or similr cost-shring chrge. SIGNTURE OF PHYSIIN (OR SUPPLIER): I certify tht the services listed ove were mediclly indicted nd necessry to the helth of this ptient nd were personlly furnished y me or my employee under my personl direction. TIE: This is to certify tht the foregoing informtion is true, ccurte nd complete. I understnd tht pyment nd stisfction of this clim will e from Federl nd Stte funds, nd tht ny flse clims, sttements, or documents, or concelment of mteril fct, my e prosecuted under pplicle Federl or Stte lws. ccording to the Pperwork Reduction ct of 99, no persons re required to respond to collection of informtion unless it displys vlid OM control numer. The vlid OM control numer for this informtion collection is The time required to complete this informtion collection is estimted to verge 0 minutes per response, including the time to review instructions, serch existing dt resources, gther the dt needed, nd complete nd review the informtion collection. If you hve ny comments concerning the ccurcy of the time estimte(s) or suggestions for improving this form, plese write to: MS, ttn: PR Reports lernce Officer, 700 Security oulevrd, ltimore, Mrylnd -80. This ddress is for comments nd/or suggestions only. DO T MIL OMPLETED LIM FORMS TO THIS DDRESS.

4 PT. TYPE NTL # OF ILL.MED. RE. # FED.TX. STTEMENT OVERS PERIOD 7 THROUGH 8 PTIENT NME 9 PTIENT DDRESS c d 0 IRTHDTE DMISSION ONDITION ODES DTE HR TYPE SR DHR 9 DT 0 7 STT STTE e OURRENE OURRENE OURRENE OURRENE OURRENE SPN OURRENE SPN 7 ODE DTE ODE DTE ODE DTE ODE DTE ODE THROUGH ODE THROUGH 8 9 VLUE ODES 0 VLUE ODES VLUE ODES ODE MOUNT ODE MOUNT ODE MOUNT c d REV.D. DESRIPTION HPS / RTE / HIPPS ODE SERV.DTE SERV.UNITS 7 TOTL HRGES 8 N-OVERED HRGES PGE OF RETION DTE TOTLS 0 PYER NME HELTH PLN ID REL. INFO SG. PRIOR PYMENTS EST.MOUNT DUE EN. 7 OTHER PRV ID 8 INSURED S NME 9 P.REL 0 INSURED S UNIQUE ID GROUP NME INSURNE GROUP. TRETMENT UTHORIZTION ODES DOUMENT ONTROL NUMER EMPLOYER NME DX 7 D E F G H I J K L M N O P Q 9 DMIT 70 PTIENT 7 PPS 7 7 DX RESON DX c ODE EI c 7 PRINIPL PROEDURE. OTHER PROEDURE. OTHER PROEDURE 7 ODE DTE ODE DTE ODE DTE 7 TTENDING QUL LST FIRST c. OTHER PROEDURE d. OTHER PROEDURE e. OTHER PROEDURE ODE DTE ODE DTE ODE DTE 77 OPERTING QUL LST FIRST 80 REMRKS 8 78 OTHER QUL LST FIRST 8 c 79 OTHER QUL U-0 MS-0 PPROVED OM d LST FIRST Ntionl Uniform NU illing ommittee THE ERTIFITIONS ON THE REVERSE PPLY TO THIS ILL ND RE MDE PRT HEREOF.

5 U-0 TIE: THE SUMITTER OF THIS FORM UNDERSTNDS THT MISREPRESENTTION OR FLSIFITION OF ESSENTIL INFORMTION S REQUESTED Y THIS FORM, MY SERVE S THE SIS FOR IVIL MONETRTY PENLTIES ND SSESSMENTS ND MY UPON ONVITION INLUDE FINES ND/OR IMPRISONMENT UNDER FEDERL ND/OR STTE LW(S). Sumission of this clim constitutes certifiction tht the illing informtion s shown on the fce hereof is true, ccurte nd complete. Tht the sumitter did not knowingly or recklessly disregrd or misrepresent or concel mteril fcts. The following certifictions or verifictions pply where pertinent to this ill:. If third prty enefits re indicted, the pproprite ssignments y the insured /eneficiry nd signture of the ptient or prent or legl gurdin covering uthoriztion to relese informtion re on file. Determintions s to the relese of medicl nd finncil informtion should e guided y the ptient or the ptient s legl representtive.. If ptient occupied privte room or required privte nursing for medicl necessity, ny required certifictions re on file.. Physicin s certifictions nd re-certifictions, if required y contrct or Federl regultions, re on file.. For Religious Non-Medicl fcilities, verifictions nd if necessry recertifictions of the ptient s need for services re on file.. Signture of ptient or his representtive on certifictions, uthoriztion to relese informtion, nd pyment request, s required y Federl Lw nd Regultions ( US 9f, FR., 0 US 07 through 08, FR 99) nd ny other pplicle contrct regultions, is on file.. The provider of cre sumitter cknowledges tht the ill is in conformnce with the ivil Rights ct of 9 s mended. Records dequtely descriing services will e mintined nd necessry informtion will e furnished to such governmentl gencies s required y pplicle lw. 7. For Medicre Purposes: If the ptient hs indicted tht other helth insurnce or stte medicl ssistnce gency will py prt of his/her medicl expenses nd he/she wnts informtion out his/her clim relesed to them upon request, necessry uthoriztion is on file. The ptient s signture on the provider s request to ill Medicre medicl nd non-medicl informtion, including employment sttus, nd whether the person hs employer group helth insurnce which is responsile to py for the services for which this Medicre clim is mde. 8. For Medicid purposes: The sumitter understnds tht ecuse pyment nd stisfction of this clim will e from Federl nd Stte funds, ny flse sttements, documents, or concelment of mteril fct re suject to prosecution under pplicle Federl or Stte Lws. 9. For TRIRE Purposes: () The informtion on the fce of this clim is true, ccurte nd complete to the est of the sumitter s knowledge nd elief, nd services were mediclly necessry nd pproprite for the helth of the ptient; () The ptient hs represented tht y reported residentil ddress outside militry medicl tretment fcility ctchment re he or she does not live within the ctchment re of U.S. militry medicl tretment fcility, or if the ptient resides within ctchment re of such fcility, copy of Non-vilility Sttement (DD Form ) is on file, or the physicin hs certified to medicl emergency in ny instnce where copy of Non- vilility Sttement is not on file; (c) The ptient or the ptient s prent or gurdin hs responded directly to the provider s request to identify ll helth insurnce coverge, nd tht ll such coverge is identified on the fce of the clim except tht coverge which is exclusively supplementl pyments to TRIRE-determined enefits; (d) The mount illed to TRIRE hs een illed fter ll such coverge hve een illed nd pid excluding Medicid, nd the mount illed to TRIRE is tht remining climed ginst TRIRE enefits; (e) The eneficiry s cost shre hs not een wived y consent or filure to exercise generlly ccepted illing nd collection efforts; nd, (f) ny hospitl-sed physicin under contrct, the cost of whose services re llocted in the chrges included in this ill, is not n employee or memer of the Uniformed Services. For purposes of this certifiction, n employee of the Uniformed Services is n employee, ppointed in civil service (refer to US 0), including prt-time or intermittent employees, ut excluding contrct surgeons or other personl service contrcts. Similrly, memer of the Uniformed Services does not pply to reserve memers of the Uniformed Services not on ctive duty. (g) sed on United Sttes ode 9cc()()(j) ll providers prticipting in Medicre must lso prticipte in TRIRE for inptient hospitl services provided pursunt to dmissions to hospitls occurring on or fter Jnury, 987; nd (h) If TRIRE enefits re to e pid in prticipting sttus, the sumitter of this clim grees to sumit this clim to the pproprite TRIRE clims processor. The provider of cre sumitter lso grees to ccept the TRIRE determined resonle chrge s the totl chrge for the medicl services or supplies listed on the clim form. The provider of cre will ccept the TRIRE-determined resonle chrge even if it is less thn the illed mount, nd lso grees to ccept the mount pid y TRIRE comined with the cost-shre mount nd deductile mount, if ny, pid y or on ehlf of the ptient s full pyment for the listed medicl services or supplies. The provider of cre sumitter will not ttempt to collect from the ptient (or his or her prent or gurdin) mounts over the TRIRE determined resonle chrge. TRIRE will mke ny enefits pyle directly to the provider of cre, if the provider of cre is prticipting provider. SEE FOR MORE INFORMTION ON U-0 DT ELEMENT ND PRINTING SPEIFITIONS