Get Medical Necessity Form Out-of-network - Upmc Health Plan

Filling out the Medical Necessity Form Out-of-Network for UPMC Health Plan can seem daunting, but with clear instructions, you can complete it accurately. This guide will walk you through each section and field of the form to ensure a smooth process.

Follow the steps to complete the form effectively.

1. Use the ‘Get Form’ button to access the Medical Necessity Form and open it in your preferred editor.
2. Begin by entering the patient's last name and first name in the designated fields. Ensure that the names are spelled correctly for accurate identification.
3. Fill in the patient's date of birth and insurance ID number. These details are crucial for the processing of the request.
4. Provide the patient's address and phone number. This information is essential for contact purposes during the review of the request.
5. Indicate if the patient has other insurance. This helps UPMC Health Plan understand the patient's coverage options.
6. Complete the referring physician's details, including their name, office contact information, address, and phone number. The referring physician must be a network provider.
7. Ensure the referring physician signs in the appropriate section, confirming their approval of the request.
8. Fill out the out-of-network provider's information, including contact details and specialty. Ensure all information is accurate and complete.
9. Describe the service or procedure being requested, including symptoms or diagnosis, using the most appropriate ICD-9 codes.
10. List the service or procedure codes using the appropriate CDT, CPT®, or HCPCS codes to provide clarity regarding the request.
11. Indicate whether the requested service or procedure is available in-network by checking 'Yes' or 'No.'
12. Specify the nature of the visit (office follow-up visit, inpatient, outpatient procedure, etc.) and the expected number of visits.
13. Indicate the duration of the services, providing start and end dates in the format indicated.
14. Explain the reason for the out-of-network request in detail. Providing comprehensive information can aid in the approval process.
15. Attach any additional documentation that may support the request, such as progress notes, labs, or consultation reports.
16. Once all sections are completed, review the form for accuracy and save your changes. You can then download, print, or share the form as needed.

Start completing your Medical Necessity Form online today for a smoother request process!