Managed Care Information Summary Sheet

October 31, 2012

Use this form to summarize all of the requirements for each of your managed care relationships. This form should be accompanied by each related provider agreement and kept in a notebook for easy access.

To download this information sheet, click here: Managed Care Info Sheet.doc



Health Plan:

Type: Contracting Entity:
Payment Method:  _____ FFS  _____ Cap _____ Withhold Renewal Terms:
Phone: Termination Requirements:
Provider Representative: Initial Date of Participation:



Eligibility: Annual Deductible per Patient/Family:
Benefits: Benefits with Max Dollar Limits:
Co-payments: Major Benefits Excluded:


Pre-Authorization Requirements:

  Yes No   Yes No
Surgery:       Outpatient Authorization:    
2nd Surgical Opinions: Emergency Room:
Specialist Referrals: Lab Services:
Hospital Admissions: Office Procedures:
Radiology: Preventive Services:
Physical Therapy: Continued Stay Review Program:
Pregnancy Ultrasound: Drug Formulary Used:
Maternity Services:


Participating Physicians:

List Physicians, Specialties and Phone Numbers

Claims Submission:

List address and other specifications, including number of days to file claims and appeals


Approved Providers

Hospitals: Physical Therapy:
Laboratories: Maternity Services:
Radiology: Ambulatory Services:
Ultrasound: Pharmacy:


Patient Eligibility:

Specify plan’s procedure for notifying practice of patient eligibility.  Note patient’s identifying documentation, including i.d. cards, etc.


Phone List:


Name Phone Fax
General Information:
Provider Relations:
Medical Director:
Benefits Verification:

Appeals Address:



To download this information sheet, click here: Managed Care Info Sheet

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