Get Request For Psychological Testing Precertification - Upmc Health Plan

This guide provides clear and detailed instructions for completing the Request For Psychological Testing Precertification form for UPMC Health Plan online. Ensuring that all sections are accurately filled out is essential for a timely review and approval process.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter today's date in the designated field at the top of the form.
3. Fill in the member's name and ID number as well as their date of birth (DOB) in the respective sections.
4. Specify the person or agency making the request for testing by selecting one of the provided options such as PCP, psychiatrist, or school staff.
5. Provide information about the referring provider, including their name, degree, address, and contact information.
6. Similarly, fill out the testing provider information, ensuring to include the name, degree, address, and contact details.
7. List the current or provisional DSM-IV codes and descriptions that relate to the testing request.
8. Clearly articulate the referral question that needs to be answered by the testing and describe the current symptoms related to this question.
9. Explain how the results of testing could influence the treatment plan.
10. Indicate what information testing is expected to provide that cannot be determined through other means.
11. Answer the medical/psychological evaluation questions regarding prior interviews, testing, and prescribed medications.
12. If applicable, detail any current substance use of the member.
13. Select the requested testing by indicating the appropriate CPT code and filling in the date of administration along with the names and types of tests.
14. Add any additional comments that may support the request for psychological testing.
15. Once you have filled out all sections, save your changes, and you may choose to download, print, or share the form.

Complete the Request For Psychological Testing Precertification form online to ensure effective processing.