Managed Care Information Summary Sheet

October 27, 2012

Health Plan: ________________     Contracting Entity: ______________________

Type: _____________________      Renewal Terms: ________________________

Payment Method:                            Termination Requirement: ________________

___ FFS                                         ___________________________________

___ CAP                                         Initial Date of Participation: _______________

___ Withhold

Phone: ______________________

Provider Rep: _________________

Comments: ___________________

___________________________

___________________________

Eligibility/Benefits/Co-Payments

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, Specialists 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. card, etc.

Phone List:

 

Department
Name
Phone
Fax

General Information:

Provider Relations:

Pre-certification/Authorization:

Medical Director:

Claims:

Benefits Verification:

Appeals:

Appeals Address:

 

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