UnitedHealthcare Community Plan CRS - Provider Service Requisition Form (PSR)
THIS FORM IS TO BE COMPLETED BY THE CRS MSIC OR PROVIDER AND FAXED TO UnitedHealthcare Community Plan CRS AT 888-899-1499 or CALL 866-604-3267
Part A
REQUI SIT I O N DATE: _______ _____ _____ ___________ ______ _
Member Inform ati on (Last Name, First Name, MI):
Date of Birth:
Presenti ng Diagnosis:
CRS ID#:
Assigned CRS Clinic:
Requesting CRS Clinic (if differe nt):
CRS Enrolled Diagnosis:
Other Insuran ce (T PL): ________ __ __ _________ __
___
Policy #s: _______ ____ ____ _ _ __ _ _ __ _ _ __ _ __ _ _ __ _ _
Part B
REFERRING CLINIC
Audiology
Cardiac
Cerebral Palsy
Craniofacial/Orofac ia l IDT
Cystic Fibrosis
Dental
Dermatology
Ear, Nose & Throat
Endocrine
Gastroenterology
Genetics
Metabolic IDT
Nephrology
Neuro
Neu ro fibro mat os is
Neurocutaneous
Neurosurgery
Nutrition
Ophthalmology
Orthodon tia
Ortho – Amputee
Ortho – CP
Ortho - Hand
Ortho – Scoliosis
Ortho Spina Bifida -MM
Pediatric Clinic
Pediatric Surgery
Physical Medicine
Physical/O ccu patio nal Therapy
Plastic Surgery
Psychiatry/Psychology
Pulmonary
Rheumatology
Sickle Cell/Hematology
SNHL
Spasticity IDT
Speech Therapy
Spina Bifida – MM IDT
Urology
Wound Clinic
Wheelchair Clinic
Other (define):
INSTRUCTIONS
This authorizatio n validates medical necessi t y only. Paym ent for servi ces is depend ent upon the member’ s eligibility at the time servi ces are rendered.
MEMBER ELIGIBILIT Y MUST BE V E R IF IED BEFORE P RO VI DING SERVICES
Part C Type of Request:
Part D
Initial Service Request
Expedited
MEDICAL REFERR AL L / SERVIC E TY PE
R EQUES T ED
Place of Service
Consultation
Field Clinic
Physician Office
Clinic/Office Visit - Date of Service ___ /
Home
Medical / Surgical
Surgery Date ____ _/__
Outpatient
Admit Date: ___
/_
_/
_
Specialist
Dental
Medical
Surgical
Medical Diagnos tic Testing
ECHO (Location) ____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_/
Auth not required if echo is completed within a M SIC
Out of State/ Net w o r k
Location (city/s tate ):
Confirmation of necessity is required for Out of State services:
____________________________________________________________
Name of Physician
___________________________
Address: _____________________________________________________________
Specialty: _______________________AHCCCS ID:____________
Service Request
Type of Service
To confi rm diagnosi s (list, if applicable):
____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
Inpatient
/_
Continuing
Standard
Genetic T esting
PET Scan
Metabolic Testing
Other __________________________
Psychological/Neurological testing
Neuropsychological Testing
On (date):_______/_______/______
Home Health Care
Skilled Nursin g Visits
Infusion
Other
Rehab/Th erap ies
PT
OT
SP
DME
Wheelch air
Prosthet ics /Orth otics
Hearin g Aids
Other: ____
____
Type
Purch as e
Rental
Phone: (____) _________________Fax: (_____)_________________
BEHAVIORA L HEALTH REFERR AL / SERVIC E TY PE
R EQUEST ED
Part E
Place of Service
Acute Inpatient Facility
Residential Treatment Center Level I
Theraputic Group Home (TGH) Level II Group Home -H0018
Admit Date: ___
/_
_/
_
Home Care Training Client (HCTC) – S5109
Type of Service
Non Par Behavioral Health Consultation
or Treatment:
Name of Physician/facility Specialty:
Special Request
Out of State/Network
Location
(city/state):________________
_________________________________
_____________________ Confirmation of necessity is required
On (date):_______/_______/______
for Out of State services:
Phone: (____) _________________
_______________________________
Fax: (_____)___________________
_____________________________________________________
Neuropsychological Testing
Name of:
Physician/facility:_______________
______________________________
Specialty:
_______________________
On (date):_______/_______/______
Phone: (____)
_________________
Prior Autho ri z at i on MUST be Obtain e d Prior to Renderin g of non-Em er g en cy Servi ce s.
Part F
Please Attach Any Pertin e nt Chart Notes, Lab/X-Ray Repo rt s With PSR request.
REFERR ING/REQUESTIN G PHY SICIAN/PROVIDER INFORMATION
RE QUE S TING P HY S ICIA N NA M E (FIRS T A ND LA S T NA M E )
CRS CLINIC
Physician Office Visit
S P E CIA LTY
P HONE NUM B E R
CONTA CT P E RS ON TITLE
FA X NUM B E R
A DDRE S S of RE QUE S TING P HY S ICIA N
CONTA CT P E RS ON (FIRS T A ND LA S T NA M E )
Part G
SERVICING PROVIDER INFORMATION (All requests must be for the same billing #)
(P HY S ICIA N, A GE NCY , P ROV IDER)
NA M E :
S P E CIA LTY
A DDRE S S (N O., S TRE E T, CITY , STA TE , ZIP )
Part H
In CRS CLINIC
TIN #
SERVICING FACILITY INFORM ATION
DA TE OF P ROCE DURE
A DDRE S S (N O., S TRE E T, CITY , STA TE , ZIP )
TIN #
Part I
P HONE NUM B E R
A HCCCS ID #
(All requests must be for the same billing #)
(FA CILITY ) NA M E :
Outside of CRS CLINIC
FA X NUM B E R
In CRS CLINIC
Outside of CRS CLINIC
P HONE NUM B E R
A HCCCS ID #
FA X NUM B E R
PROCE D UR E /SER V IC E INFORMATION
REQU E S T E D SERVIC E
CPT / HCPS
CODE
(P ROCE D U R E
CODES)
# UNITS
FREQU E N C Y
FROM
TO
REAS O N FOR SERVIC E
UnitedHealthcare Community Plan Children’s Rehabilitative Services
Purpose of the Provider Service Requisition (PSR) Form
The purpose of this form is to provide any physic ia n with a desig na ted form to reque st service s in suffic ie nt scope and duratio n to meet the medica l need s of a
CRS enrolle d diagn osis. Refe rr ing physic ian s will use this form for elective CRS refer ra ls that require obtainin g prior author iza tion from the Intake Prior
Author iz ation Unit. T he form is not used for requesting services at the MSIC.
Valid Authorizations
Author iza tions are valid only if the CRS membe r is enrolle d with Unite dHe a lthc ar e Comm unity Plan CRS on each date of servic e. Services must be provide d
within three days prior to or after the date( s) of servic e authoriz e d. Gener ally, authoriz atio ns are valid for 90 calenda r days
from the date of reques t and for a design ate d numbe r of units/visits. Please call to verify the prior authoriza tion number and date(s) of servic e
authorized.
Part A
1.
2.
3.
4.
5.
6.
7.
8.
9.
Enter date form is completed
Enter membe r ’s last name first and first name
Enter membe r ’s date of birth
Enter CRS ID#
Enter Name of Assign ed Clinic Site
Enter Name of Reque sting Clinic Site, if different
Enter Membe r ’s prese nting diagn osis as the basis for the procedu re /se r vic e s requested
Enter Membe r ’s enrolling CRS diagno sis that is relevant to this specific authorization
Identif y any third party liability coverage
i.
Enter other insuran ce carrie r’ s name
ii. List other insuran ce policy number, if available
Part B
1. Completed by the MSIC clinic only: Select specia lty clinic reque stin g service
2. If specia lty clinic is not listed, select “Other”: and define clinic by name
Part C Enter type of request, Expedite d or Standard
1.
a.
b.
Expedite d is indic a ted or deter m ine d by the provide r or United He a lthc ar e Comm unity Plan CRS medic al director that serious jeopar dy of the
membe r’ s life, health or ability to maintain or regain maxim um function may result if the reque st is proce ss ed using standa rd timef ra m e s (14
calen da r days).
Select “Initia l Servic e Reque st” for first or separa te reque st for this servic e or “Continuing Servic e ” if the reque st is for an additional reque st for
service s that are curre ntly being provided.
Part D
1. Place of Servic e – Select place where service will be performed
a. Indic a te date of Office Visit, if appropriate b.
Indic a te date of Surge ry, if appropriate
c. Indic a te date of Admission, if appropriate
d. Indic a te City and State of facility for out of state admission
i.
Confir m a tion with physicia n of same specialty in anothe r region is requir e d for all Out of State requests
ii. Enter Physic ian Name
iii. Specialty
iv. Date of conversation
v. Phone numbe r of consu lted physician
2. Type of Serv ice – Select appro pr iate categ or y of servic e being requested
a. Select specialty clinic requesting service
b.
DME- select type and if purchase or rental.
Part E
1. Be h av io r al Healt h - Place of Serv ice – Select place wher e servic e will be performed
a. Indic a te date of Office Visit, if appropriate
b. Indic a te date of Admission, if appropriate
c. Indic a te City and State of facility for out of state admission
d. Neuropsychological T esting
e. Level I, II, III Behavioral Health facility
I.
Confir m a tion with physicia n of same specialty in anothe r region is requir e d for all Out of State requests
II.
Enter Physic ian Name
III.
Specialty
IV.
Date of conversation
V.
Phone numbe r of consu lted physician
Part F
1. Select whethe r this reque st was the result of a visit in the CRS Clinic or a physicia n office visit
2. Enter the name and specialty of the physic ian who wrote the order for the request
3. Enter the contact informa tion for the person comple ting the form (First and Last Nam e, Phone and Fax numbe rs). This should be the name and numbe r
of the individ ual who can answe r question s conce r ning the reque st and the fax numbe r where the response is to be forw a rd e d to.
Part G & Part H
1. Enter the Name, Address, Phone, Fax, Tax Id. (TIN #) and AHCCCS ID for the Provide r or Facility providing and being paid for the services
Examples:
a. Name of Thera pist in a CRS Clinic for a PT, OT or ST request along with the CRS Clinic addres s, phone and fax information
b. Physic ian, specialty, office inform atio n for reque sts for an Office Visit
c. IP or OP facility infor m a tio n for proce du re s, surge r ies or diagno stic tests requiring
d. DM E, Orthotic or Prosthe tic comp a ny info for requests for Whee lc ha irs or other equipment
e. Home Health Compa n y for nursing visits or infusion services
Part I
1.
2.
3.
4.
5.
6.
Enter
Enter
Enter
Enter
Enter
Enter
descrip tion of reque ste d service
CPT /HCPS Codes for reques ted services
#of Units/Visits
freque nc y of service s, if applicable
dates of service
reason for service
Doc#: PCA-1-004471-12132016-01092016