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Get This Form Should Not Be Used If The Member Has An Hphhmo Plan
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How to fill out the THIS FORM SHOULD NOT BE USED IF THE MEMBER HAS AN HPHHMO PLAN online
Filling out the Travel Assistance Request Form accurately is essential to ensure your request is processed efficiently. This guide provides a clear, step-by-step approach to help you complete the form online while avoiding common mistakes.
Follow the steps to successfully complete the Travel Assistance Request Form.
- Press the ‘Get Form’ button to access the form and open it for editing.
- Begin with section A, which includes member information. Enter the membership number, patient’s name, and date of birth. If there is a companion under the age of 17, include their name and specify if the companion is a parent, legal guardian or other.
- In section B, specify the ICD-9-CM diagnosis code. Ensure this information is accurate as it is critical for processing your request.
- Move to section C, where you need to enter the procedure, service, or treatment information. Input the required CPT/HCPCS code(s) along with the date and time of the appointment.
- Proceed to section D, which entails provider information. Enter the requesting provider's name, provider ID, and contact details. Do the same for the servicing specialty provider if applicable.
- In section E, provide a brief explanation of why the patient requires a referral to a specialist provider. Be clear and concise in your description.
- Once all sections are completed, review the information for accuracy. You can then save your changes, and you have the option to download, print, or share the completed form.
Complete your Travel Assistance Request Form online today to ensure prompt processing of your request.
Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage.
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