Modifier Details

Boston Medical Center Healthnet is a company that specializes in healthcare information technology. Their goal is to provide an effective care delivery system for physicians, hospitals and consumers by assisting them with the management of electronic health records, patient scheduling, administrative tasks and more. They are committed to delivering high quality services through their innovative solutions which help improve the efficiency of medical practices around the world. Boston Medical Center Healthnet has been serving clients since 1989 and have become leaders in their field due to their commitment to customer satisfaction as well as continued innovation. Interested readers can visit bostonmedicalcenterhealthnet.com/blog or call 1-800-898-0662 for more information on our services today.

The listing provides details about the boston medical center healthnet. You'll have the assumed time it may require you to fill in the form plus some additional details.

QuestionAnswer
Form NameBoston Medical Center Healthnet
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesNorthwood, Modifier, DMEPOS, PCP

Form Preview Example

MEDICAL PRIOR AUTHORIZATION REQUEST FORM

NOTE: PLEASE ATTACH SUPPORTING CLINICAL INFORMATION WITH ALL REQUESTS

INCOMPLETE INFORMATION MAY DELAY PROCESSING OF REQUEST

FAX TO: 617-951-3464 - initial requests; 617-951-3461 - additional clinical; 617-951-3463 - emergency and inpatient

.

Member Information

Member Name: _______________________________________________ DOB: ____________ BMCHP ID #: ____________________

Submitted by / Sender Information

Submitted by: ___________________________________________ Phone # (direct line): ________________ Fax #: _______________

Who sent in the form?

Provider Information

Requesting Provider Name: ____________________________________________ NPI #: ____________________ PCP Specialist

Servicing Provider/Group Name: _____________________________________/_____________________ NPI #: ___________________

Individual’s name and group name if affiliated with multiple groups

Servicing Provider Address: _____________________________________________ Phone #: ________________ Fax #: ____________

At what address will member be seen?

Servicing Facility Name:_____________________________________________________________ NPI #: _______________________

Requested Services

Office Visit / Consult: Primary Care OB: EDC (required) ____________ Specialist: Type: ___________________________

Visit Date: Scheduled: _________ Most Recent: _________ # Visits: _____ Required Codes: Diagnosis: __________ CPT: _________

Surgery: Inpatient Outpatient Post-op Observation: _______hours Scheduled date: _______________

Required Codes: Diagnosis: _______________ CPT: _______________

Outpatient Rehab: PT: # visits ______ Date range: ________________ OT: # visits _____ Date range: ________________

ST: # visits ______ Date range: ________________

Required Codes: Diagnosis: _______________ CPT: _______________

Home Health Care: RN: # visits _______

Date range: ____________

PT: # visits _________

Date range: ____________

OT: # visits _______

Date range: ____________

ST: # visits _________

Date range: ____________

SW: # visits _______ Date range: ____________

HHA: # visits _______

Date range: ____________

Other: _________ # visits _______ Date range: ____________

Specify type

Required Codes: Diagnosis: _______________ CPT: _______________

DMEPOS**: HCPCS Code Modifier DescriptionQuantity (Units/Calories) Cost

___________________________________________________________________________________________

___________________________________________________________________________________________

**For DMEPOS provider requests and requests for oral enterals by any provider, contact Northwood at 866-802-6471 for authorization.

Additional Comments:

The number you will receive from the BMC HealthNet Plan Prior Authorization Department is a reference number; it is not a guarantee of payment. Payment is based upon eligibility of the member on the date of service, verification of the service as a covered benefit, and medical necessity. Submission of cost or charge information does not guarantee payment at those rates.

Member service ph# 1-888-566-0010 (MassHealth); 1-877-957-5300 (Commonwealth Care); 1-877-492-6967 (Commercial)

Provider line ph# 1 -888-566-0008

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