Health Plan Appeal Form PDF Details

Navigating through the healthcare system can often feel like a maze, with each turn presenting a new challenge. One such challenge is when a patient or a healthcare provider feels the need to question or contest a decision made by a health plan. This is where the Health Plan Appeal form plays a crucial role. Designed as a formal request for review, this document is filled out with details such as patient information, referring and referred physicians, and specific services requested, all aimed at persuading the health plan to reconsider its initial decision. It's a document that demands meticulous attention to detail - from ensuring all sections are completed in blue or black ink to attaching any necessary clinical information. The form underscores the importance of verifying member eligibility and understanding that a referral does not guarantee payment. It brings to light the various ways in which care can be sought, underlining the significance of specifying the type of service requested, be it for behavioral health, maternity services, or surgery among others. Moreover, the appeal process underscores the health plan's response options, which range from approval to denial, and highlights the urgency levels that can be marked, illustrating the form's flexibility in accommodating various patient needs. This form serves not only as a means to challenge an unfavorable decision but also as a reflection of the intricate web of policies, procedures, and regulations that govern healthcare services.

QuestionAnswer
Form NameHealth Plan Appeal Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdriscoll childrens chips appeal form, driscoll health plan prior authorization form, driscoll prior authorization form pdf, driscoll health plan authorization phone number

Form Preview Example

Texas Referral/Authorization Form

Please fill out form completely in blue or black ink. Refer to instruction sheet.

This referral does not guarantee payment. Please contact health plan to verify member eligibility and covered benefits.

CHIP STAR/Medicaid OTHER_____

HEALTH PLAN NAME:

________________________ DATE ____/____/____

 

Health Plan Fax# 1-866-741-5650

PATIENT INFO.

 

 

 

 

Patient name ______________________________________________________________

LAST

FIRST

MIDDLE INITIAL

DOB ______/________/______ Sex MFPhone # (____)____________________

Member ID #____________________ Member Social Sec. # ______-_________-________

 

 

OPTIONAL

REFERRED BY

 

 

Physician name __________________________________________________________

LAST

FIRST

M.I.

Provider # _________________________________

PCP SCP HOSPITAL

 

 

 

Fax # (______)____________________

Contact name __________________________ Phone # (_____)_________________

REFERRED TO

Provider name ____________________________________________________________

LASTFIRSTM.I.

Specialty type ___________________________ Provider/Facility # _________________

Fax # (_____)____________________ Phone # (_____)_______________________

Provider City ____________________________, Texas

REFERRED TO LOCATION

Office Outpatient facility*** Inpatient 23 Hour observation

***Note for outpatient facility, List CPT4 at right

ER/Post Stabilization Other Date of service _______/________/______

Facility name _____________________________________________________________

Facility # * _____________________________* Required for ER/UCC, Therapy and Outpatient services.

COMMENTS/CLINICAL HISTORY __________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Clinical information attached:

Y / N

# of pages _____

PHYSICIAN SIGNATURE-

_________________________________________________

The information contained in this form is privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited If this communication has been received in error, the reader shall notify sender immediately and shall destroy all information received.

HEALTH SERVICES RESPONSE

Approved as requested

Authorization # ___________________

 

Expiration date ______/______/______

 

Days authorized _____

ROUTINE URGENT

EMERGENCY

OUT OF NETWORK

REVISED REFERRAL

NOTIFICATION ONLY

Requested

Start date ____/_______/_______

Requested

End date _____/_______/_______

ICD-9/DSM4/Diagnosis_________

______________________________

Scope of referral

Consultation

Diagnostic Testing

Follow-up

Number of visits _____

SPECIFIC SERVICES REQUESTED**

**Refer to specific plan instructions.

Certification/authorization guidelines must be followed.

Behavioral Health

Dialysis

DME/Prosthesis/Supplies

Case Mgmt. ___________________

_____________________________

Health Educ. __________________

_____________________________

Home Care

Injections and IV Therapy

Maternity Services:

EDC ________________________

Vaginal C-Section

Lab/Pathology

Radiology/ Imaging

Therapy: Indicate # of visits ________

Physical Cardiac Rehab

Speech Occupational Visits/Week _____

Surgery ____________(CPT4 code)

Assistant Surgeon

TO AUTHORIZE ONLY (OR OTHER) SPECIFIC SERVICES, INCLUDE CPT4 /MEDICAID LOCAL OR HCPCS CODES HERE.

_____________

_____________

_____________

_____________

_____________

_____________

Medical Director Review Pending Info. No referral needed Denied Approved with modification

NOTES ________________________________________________Signature _____________________________Date: ___/___/_____

Revised 12-15-00