Get Mental Health Retrospective Review Request Form - Provider Express

Completing the Mental Health Retrospective Review Request Form online is a crucial step for securing necessary mental health services. This user-friendly guide will walk you through each section of the form, ensuring you complete it accurately and efficiently.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling out the member information section. Enter the member's name, date of birth, Medica ID number, and address. Ensure that all details are accurate to avoid processing delays.
3. In the provider information section, provide the name of the provider or facility. Indicate the provider's network status at the time the services were rendered by checking either 'Participating' or 'Non-Participating'. Include the provider's address and phone number along with a contact name.
4. Next, specify the mental health requested level of care or services. Check only one option from inpatient, outpatient, partial, intensive outpatient, or other. If you choose 'other', ensure you include a narrative description of the services requested.
5. Fill out the dates section by entering the first and end dates of the service(s) requested. Indicate the number of days or sessions being requested along with the appropriate CPT or HCPCS codes for outpatient services.
6. If you are submitting a request for substance abuse treatment, indicate whether the treatment services are billed per diem or hourly by checking the appropriate box. Fill in the relevant dates and number of days or hours requested, along with the corresponding CPT or HCPCS codes.
7. Complete the program specifics/modifiers section by checking all that apply, indicating special populations or services relevant to the treatment being requested.
8. Finally, review the completed form for accuracy. Once satisfied, save your changes. Depending on your preferences, you may download, print, or share the form as needed. Ensure to submit the form to Medica Behavioral Health via mail or fax as instructed.

Start completing your Mental Health Retrospective Review Request Form online today to ensure timely access to necessary services.