Ash Mnr Form – Fill Out and Use This PDF

The Ash MNR form is a comprehensive document utilized for acupuncture treatment, specifying patient information, diagnosis, treatment services, and clinical findings to American Specialty Health (ASH). It serves as a crucial communication tool between acupuncture practitioners and ASH, ensuring a streamlined process for claims and treatment approvals. For those seeking acupuncture care under ASH plans, completing and submitting this form is an essential step.

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Ash Mnr Form PDF Details

For many people dealing with health conditions that require specialized care, navigating the sea of paperwork can be overwhelming. One critical document in the domain of acupuncture treatment is the American Specialty Health (ASH) Managed Network Request (MNR) form, designed for practitioners to submit patient treatment details to ASH for review and approval. This comprehensive document, sent to ASH's address in San Diego, California or via fax, requires detailed information starting from basic patient identifiers such as name, sex, and birthdate, to more intricate details about the condition being treated, including diagnosis, ICD-9 codes, and the specifics of the acupuncture treatment plan. It covers treatment service submission for review, details about the patient's response to previous treatments, including pain and functional ability assessments, and a summary of examination findings to justify the need for ongoing care. Notably, it extends to capturing additional clinical findings that may influence the patient's treatment plan, including pain descriptions, clinical findings related to the pain, and other symptoms or diagnostic findings that support the treatment strategy. In essence, the ASH MNR form plays a pivotal role in ensuring patients receive the necessary acupuncture treatments by providing a structured pathway for practitioners to communicate detailed patient care and treatment plans to ASH.

Question	Answer
Form Name	Ash Mnr Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	286
Avg. time to fill out	28 min 53 sec
Other names	ash form physical therapy, ash mnr form physical therapy, cigna ash medical necessity review form physical therapy, cigna ash mnr form

Form Preview Example

American Specialty Health (ASH)

P.O. Box 509001, San Diego, CA 92150-9001

Fax: 877.248.2746

FOR ASH	ASH MNR FORM #
USE ONLY

MNR FORM – Acupuncture - Page 1

For questions, please call ASH at 800.972.4226

	RECEIVED DATE	ASH CLINICAL QUALITY EVALUATION MANAGER

Patient Name

Sex M / F Birthdate

Patient ID #

Last

First

Initial

yyyy

Subscriber Name

Subscriber ID #

Employer

	Primary
Health Plan	Secondary Group #	Is this?
PCP Name	Phone #

Work Related? Auto Related?

Clinic Name

PATIENT MAILING ADDRESS AND PHONE NUMBER

Treating Practitioner

Address

City/State/Zip

Phone (

)

Fax (

)

Phone (

)

CONDITION TREATED, DIAGNOSIS AND ICD-9 CODE

Acute Condition

Chronic Condition

Continuing Care

Co-managed Care

Supportive Care

Eastern Diagnoses:

TREATMENT/SERVICES SUBMITTING FOR REVIEW

Date: From ___ / ___ / _____ Through ___ / ___ / _____

Acupuncture

Electro-stimulation

Acupressure/Tui-Na

Home Care Advice

Total # Office Visits/Acupuncture

Diet

Cupping

Cold/Heat Pad

GuaSha

Herbs

Infrared/Heat Lamp

Established Patient Exam Date

Moxibustion

Rehab Exercise

Nutritional Supplements

Estimated Date of Release

/ ___ __ / __ ____

Other

Treatment Goal:

Services provided prior to today and the treatment outcome:


Total # of Treatments _____ performed.			Patient’s response to care
Pain has	Decreased	No Change		Worsened	Decreased only for a short period of time
Functional Ability Change		Improving		No Change	Getting Worse. Explain:

Current main complaint(s)

Mechanism of injury/date of onset Traumatic Repetitive Exacerbation Recurrent / Chronic Unknown Post-Surgical

Pertinent health history

Other ongoing treatments (e.g., medications, therapies)

Height

____, Weight ___

lb, BP_____ / ______ mmHg,

Temperature

__, Pulse __________

Summary of your examination findings (or attach page 2): Date of exam

Findings:

Activities of Daily Living are normal

mildly affected

severely affected:

Observation

Palpation

Range of Motion

Orthopedic Testing

Neurological Assessment

Tongue Signs

, Pulse Signs R:

Additional Clinical Findings

PLEASE SUBMIT THIS FORM WITH INITIAL HEALTH STATUS (INITIAL CARE) OR PATIENT PROGRESS FORM (ONGOING CARE)

Signature of treating acupuncture practitioner		Date

AcuMNRForm041312.docx

American Specialty Health (ASH)		MNR FORM -Page 2 (OPTIONAL)
		Acupuncture Clinical Findings
Patient Name	Occupation	Practitioner Name

Pain Descriptions:

Pain Condition #1: Location ________________ Intensity (1-10) _____ Frequency_______________ Duration________ hours/days

Pain is

Sharp

Dull

Stabbing

Burning

Spasmodic

Tingling

Throbbing

Stiffness

Distension or

Aggravating factors:

Alleviating factors:

Pain Condition #2: Location

Intensity (1-10)

Frequency

Duration

hours/days

Pain is

Sharp

Dull

Stabbing

Burning

Spasmodic

Tingling

Throbbing

Stiffness

Distension or

Aggravating Factors:

Alleviating Factors:

Other Pain Conditions:

Clinical Findings Related to Pain Location:

Head:

Pain with Nausea/Vomiting Fever/Chills Dizziness Phono/Photophobia Neck Rigidity

Neurologic Deficit Sensation Strength Speech Vision Hearing Cognition Memory Eye Motion/Pupils React

Neck:

Tenderness at

Postural Abnormalities

Functional Limits

Back:

Mild	Moderate	Severe	Worsened.	Muscle Spasm	Mild	Moderate	Severe
		Radiating Pain To

Tenderness at ________________

Mild

Moderate

Severe

Worsened.

Muscle Spasm

Mild

Moderate

Severe

Postural Abnormalities ________________

Scoliosis _____________________

Radiating Pain To

Functional Limits

Extremities, Hip(s) and Shoulder(s)

Tenderness at _______________

Mild

Moderate

Severe

Worsened.

Muscle Spasm

Mild

Moderate

Severe

Swelling _______________ Color change __________

Deformity

Radiating pain to

Functional Limits

Neurologic Deficit Location

Weakness

Abnormal Sensation

Reflexes (Increased/Decreased)

ROM of Affected joint(s) Use measurement or indicate if ROM Within Normal Limits (WNL), mildly, moderately or severely limited:

Joints

Flexion / Extension

Lateral Flexion R / L

Rotation R / L

Rotation Int./Ext.

Abduction / Adduction

Other:

Orthopedic/Neurological Test Findings: E.g., Axial Compression ______ ; Patrick’s (Fabere) _______ ; Straight Leg Raising

Abdominal Pain:

Associate Symptoms: Fever

Nausea/Vomit

Gas/Distension

Heartburn/Reflux

Constipation

Diarrhea

Palpable Mass at

Tenderness at

Rebound Tenderness

Bowel Movement Sounds (Increase/Decrease)

Other Findings

Menstrual Pain: Menstrual Cycle

days. Other Symptoms

Additional Clinical Findings (including Lab / Radiographic Exams)

Outcome Assessments (List both Initial and Current date(s) with score(s) for applicable tests)

Initial

Current

Initial

Current

List Date Obtained

Roland-Morris score

Neck Disability Index score

Oswestry score

LEFS (Lower Extrem.) score

Pain scale (0-10) score

DASH (Upper Extrem.) score

Other

Signature of treating acupuncture practitioner

Examination Date (required)______________

AcuMNRForm041312.docx

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The system will demand you to fill out the Total, Office, Visits, Acupuncture Established, Patient, Exam, Date Diet, Cupping, Cold, Heat, Pad Gua, Sha Herbs, Infrared, Heat, Lamp Mox, i, bust, ion Rehab, Exercise Nutritional, Supplements Estimated, Date, of, Release Other, Treatment, Goal and Pain, has section.

Describe the main details about the Range, of, Motion Orthopedic, Testing Neurological, Assessment Tongue, Signs Pulse, Signs, R Additional, Clinical, Findings Date, and A, cuM, NR, Form, do, cx section.

The Patient, Name Pain, Descriptions Occupation, Practitioner, Name Aggravating, factors Alleviating, factors Pain, Condition, Location Intensity, Frequency, Duration, hours, days Aggravating, Factors Other, Pain, Conditions Alleviating, Factors and Radiating, Pain, To area is the place where each party can put their rights and responsibilities.

mnr form PatientName, PainDescriptions, Occupation, PractitionerName, Aggravatingfactors, Alleviatingfactors, PainConditionLocation, Intensity, Frequency, Duration, hoursdays, AggravatingFactors, OtherPainConditions, AlleviatingFactors, and RadiatingPainTo blanks to fill

Finish by looking at the next sections and filling them out as needed: Extremities, Hips, and, Shoulders Joints, Flex, ion, Extension Lateral, Flex, ion, RL Rotation, RL Rotation, In, tExt Abduction, Adduct, ion, Other Palpable, Mass, at Tenderness, at Rebound, Tenderness Bowel, Movement, Sounds, Increase, Decrease Other, Findings Menstrual, Pain, Menstrual, Cycle days, Other, Symptoms and Initial.

mnr form ExtremitiesHipsandShoulders, Joints, FlexionExtension, LateralFlexionRL, RotationRL, RotationIntExt, AbductionAdductionOther, PalpableMassat, Tendernessat, ReboundTenderness, BowelMovementSoundsIncreaseDecrease, OtherFindings, MenstrualPainMenstrualCycle, daysOtherSymptoms, and Initial fields to fill

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