MA Fee for Service Review Form
Demographics and Authorization Information
Patient Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
MRN
Age at Admission
MA Recipient ID
Date of Notification of Active Insurance
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Month
-
Day
Year
Date
Date MA Reviewer Notified
typically via email
Date of Admission to BHU
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Month
-
Day
Year
Date
Date of Discharge from BHU
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Month
-
Day
Year
Date
Length of Stay (How many days are being requested?)
Do not count day of discharge.
Admitting Physician MA ID Number
H&P must be completed by a physician, not a mid-level practitioner.
Authorization/PA Number
Provided by reviewer at beginning of review
Approved Days
Denied Days
Appeal or Telecon Needed?
If yes, specify date of request and date scheduled.
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Clinical Information
Commitment Information
If 302, have printed copy for reference for petitioner, county, and date filed/granted as well as expiration.
Brief Description of Presentation/Reason for Admission
Toxicology and ETOH Screening Results
If positive, what substances?
Diagnoses Upon Admission
F-code and descriptors
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Medications
PRN
Please list all PRN medications with details as listed below.
Include Name, Dosage, Date First Ordered, Date of Last Use, Number of Times Administered
Medications
Scheduled
Please list all scheduled medications with details as listed below.
Include Name, Dosage, Date First Ordered, Date of Last Use, Number of Times Administered, and Changes with Dates
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Aftercare Plan
Appointments
Include type of service, provider, and date and time of appointment if scheduled
Disposition
Home Alone, Home with Family, Group Home, Rehab, EAC, etc.
Submit
Should be Empty: