Please use the checklist when submiting TRICARE referrals through the self-service portal at HumanaMilitary.com to ensure that all necessary clinical information is included and to expedite authorization process. History of TMS? If so, please provide the following information:
Instructions: Please complete all the fields on the treatment request form. Please use the checklist when submitting TRICARE referrals through the self-service portal at HumanaMilitary.com to ensure that all necessary clinical information is included and to expedite authorization process. History of evaluation (e.g., BDI) and psychotherapy:
Please complete this form, save it to your computer, then email it to: TMSBehavioralClinical@Evernorth.com (preferred) or fax 860-687-7329. Network Exception Request
Optum: TMS Initial Authorization Request Form (Revised: Sept 2016 2. 5. Has the member been diagnosed with any other neurologic conditions? (Seizures, cerebrovascular disease, dementia, movement disorders, increased intracranial pressure, a history of repetitive or severe head trauma, primary/secondary tumors in the central nervous system) 6.
Please complete this form, save it to your computer, then email it to: TMSBehavioralClinical@Evernorth.com (preferred) or fax 860-687-7329. Network Exception Request
Forms and applications for Health care professionals - Aetna
Applications and forms for health care professionals in the Aetna network and their patients can be found here. Browse through our extensive list of forms and find the right one for your needs.
rTMS REQUEST FORM Provider must call Blue Cross Community MMAI at 877-723-7702 to verify benefits. After completing the form, fax it to 312-233-4099. Signature _____ Date _____
Fax this form with required documentation to Blue Cross NC Medicare Advantage Behavioral Health @ 336-794-1557. For questions, please call Care Management at 1-888-296-9790.
Request is for TMS of the brain. Individual is an adult. Individual has a confirmed diagnosis of severe major depressive disorder (MDD) single or recurrent episode. TMS is requested for treatment of a disorder other than severe MDD. Individual has …
Optum Forms - Provider Express
Click to see a sample 1500 form, a listing of all Optum required fields, as well as the reverse side of the 1500 Claim Form. Inpatient claims are typically submitted on a UB-04 claim form. More information is available about submitting claims on this form at the CMS site.