College Clinic 4567 Broad Avenue Woodland Hills, XY 12345-0001 Telephone No. (555) 487-8976 Fax No. (555) 487-8976 MANAG

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College Clinic 4567 Broad Avenue Woodland Hills Xy 12345 0001 Telephone No 555 487 8976 Fax No 555 487 8976 Manag 1 (215.51 KiB) Viewed 17 times

College Clinic 4567 Broad Avenue Woodland Hills Xy 12345 0001 Telephone No 555 487 8976 Fax No 555 487 8976 Manag 2 (167.51 KiB) Viewed 17 times

College Clinic 4567 Broad Avenue Woodland Hills, XY 12345-0001 Telephone No. (555) 487-8976 Fax No. (555) 487-8976 MANAGED CARE PLAN AUTHORIZATION REQUEST TO BE COMPLETED BY PRIMARY CARE PHYSICIAN OR OUTSIDE PROVIDER Debbie Hye Patient Name_ Male Female Birthdate Address 6700 Flora Road Woodland Hills, XY 12345 Primary Care Physician Dr Gerald Praction Referring Physician Dr. Gerakd practon Referred to Dr. Donald Ratos Address Consult/Procedure/Surgery Description:. Description:. Procedure Code: Procedure Code: Place of Service Office Outpatient Inpatient Other Facility: XY2 Radiology SOF Physician's Signature:. TO BE COMPLETED BY PRIMARY CARE PHYSICIAN PCP Recommendations: Date Eligibility Checked: NPI. 4466 8. CentR DRaWoodland Hills XX1234 Mone No. 555980 5566 Telephone TO BE COMPLETED BY UTILIZATION MANAGEMENT Authorized: Deferred: Effective Date:. Copyright © 2020 Elsevier, Inc. All Rights Reserved. Diagnosis Code. Diagnosis. Diagnosis Code. Diagnosis. Treatment Plom Bilateral diagnostic Mammography and Complete Body Bone Authorization Requested for: Consult Only Treatment Only Consult/Treatment Diagnostic Tests Health Net Pacificare Secure Horizons Other Member/Group No. Auth. No: Modified: Expiration Date:. Fig. 5.6 Date Oct. 23, 2022 Home Telephone Number SS54336755 NPI NPI solbeM Number of Visits: Length of Stay: PCP Initials: Met Life Travelers Pru Care Not Authorized No. of Visits: 65 Chapter 5 The Blue Plans, Private Insurance, and Managed Care Plans
ASSIGNMENT 5.6 OBTAIN AUTHORIZATION FOR DIAGNOSTIC BODY SCAN FROM A MANAGED CARE PLAN Performance Objective Task: Conditions: Standards: Complete a treatment authorization form to obtain permission for diagnostic complete body bone scan and mammogram for a patient covered by a managed care plan. Use a treatment authorization form (Fig. 5.6), computer, and printer. Time: minutes Accuracy: (Note: The time element and accuracy criteria may be given by your instructor.) Directions: Complete the treatment authorization form for this patient (see Fig. 5.6), date it October 23 of the current year, and submit it to the managed care plan. Refer to Fig. 5.2 in the Textbook for visual guidance. Scenario: A patient, Debbie Dye, sees her primary care physician, Dr. Gerald Practon, for complaint of midback pain. She underwent a lumpectomy 2 years ago for a malignant neoplasm of the lower left breast; thus she has a history of breast cancer. She has been referred by Dr. Practon (PacifiCare identification number PC C01402X) to Dr. Donald Patos, an oncologist, for a complete workup. He finds that her complaint of midback pain warrants the need to refer her to XYZ Radiology for bilateral diagnostic mammography and a complete body bone scan. Dr. Patos' address is 4466 East Canter Drive, Woodland Hills, XY 12345, and his office telephone number is 555-980-5566. Dr. Patos' PacifiCare identification number is PC 5673X. His NPI is 6520101678XX. Ms. Dye lives at 6700 Flora Road, Woodland Hills, XY 12345, and her telephone number is 555-433-6755. Her PacifiCare plan identification number is SR45380, effective January 1, 20xx. Her birth date is August 6, 1952. XYZ Radiology's address is 4767 Broad Avenue, Woodland Hills, XY 12345-0001, and the office telephone number is 555-486-9162. After the instructor has returned your work to you, either make the necessary corrections and place your work in a three-ring notebook for future reference or, if you received a high score, place it in your portfolio for reference when applying for a job.