Get Mro Request - Nebraska Total Care

This guide provides step-by-step instructions for users to complete the MRO Request form for Nebraska Total Care online. By following these instructions, you will ensure all necessary information is accurately provided for timely processing.

Follow the steps to successfully complete your MRO Request.

1. Use the ‘Get Form’ button to access and open the MRO Request form online.
2. Begin filling out the form by indicating whether this request is for Initial Authorization, Re-Authorization, or an Urgent Request. Select the appropriate option by ticking the relevant box.
3. Enter the Admission Date in the designated space. Please ensure the date format is clear and correct.
4. Specify the Authorization Start Date and Authorization End Date. These dates indicate the desired time frame for the requested services.
5. Provide the Date of Request, which is the day you are submitting the form.
6. Select your Managed Care Organization from the provided options. Make sure to note the designated fax number for submission.
7. Fill in the Provider(s) Information section, including the Program/Facility, Contact Person's name and address, and Contact Information.
8. Complete the Member Information fields with precise details such as Date of Birth and Nebraska Medicaid number. Ensure that all contact numbers are correctly written.
9. Indicate Current Diagnoses by providing relevant codes or descriptions for Psychiatric/Co-Occurring Substance Disorder and Medical conditions.
10. List Current Medications with their name, dosage, frequency, and prescriber, or select 'None.' If applicable, attach a patient medication list.
11. Provide a Justification for Authorization that includes a brief explanation of the necessity of this request. Attach any relevant treatment history and clinical documentation.
12. Explain the expectation for the consumer’s improvement based on the treatment plan goals.
13. Outline the Discharge/Transition Plan if provided in the attached Treatment Plan. Note the Date of Last Assessment/Authorization.
14. If applicable, detail any Significant Changes in the member’s life since the last assessment.
15. Specify if there has been any Inpatient Admission in the last 90 days.
16. Select the Overall Motivation to Treatment by checking the appropriate option.
17. Indicate the level of Family/Friends/Caregiver/Involvement and provide details about any less active involvement.
18. Discuss participation in Community Supports.
19. Complete the Treatment Request section by checking the required services and specifying the units, frequency, and details for each service requested.
20. For Re-Authorizations, fill in the Treatment Review section with the number of appointments attended and the type of services used from the last authorization.
21. Finally, sign and date the form where indicated to confirm the information is accurate before submission.

Complete your MRO Request - Nebraska Total Care online today to ensure timely processing of your request.