<p> MOLINA HEALTHCARE OF UTAH MEDICAL REVIEW REQUEST FORM</p><p>DATE: MEMBER INFORMATION MEMBER NAME (LAST, FIRST, MI) DATE OF BIRTH MEMBER I.D. / / AUTHORIZATION NUMBER: SERVICE REQUESTED INPATIENT Admission, Requested LOS: Surgical procedure Other, describe: </p><p>OUTPATIENT Diagnostic procedure DME Home Health Hospice Imaging Oxygen Surgical procedure Therapy (OT, PT, ST) Other: </p><p>CPT/HCPC CODES/DESCRIPTION: / ICD-9 CODE(S)/DESCRIPTION: / REQUESTING PROVIDER INFORMATION REQUESTING PROVIDER NAME (LAST, FIRST) PCP: YES NO SPECIALTY PHONE NUMBER ( ) - POINT OF CONTACT (NAME AND TITLE): FAX NUMBER ( ) - SERVICE PROVIDER INFORMATION SERVICE PROVIDER NAME (PHYSICIAN, FACILITY, AGENCY) SPECIALTY PHONE NUMBER ( ) - SERVICE FACILITY FAX NUMBER ( ) - COMMENTS</p><p>MHU MEDICAL REVIEW REQUEST FORM 1/05 VERSION</p><p>MOLINA HEALTHCARE OF UTAH MEDICAL REVIEW REQUEST FORM THIS PAGE FOR MOLINA USE ONLY PATIENT NAME (LAST, FIRST) MHU ID: TYPE OF REVIEW Pre-service, routine PLAN TYPE ELIGIBILITY SCREEN BENEFIT COVERAGE Medicaid Traditional Eligibility confirmed Covered Benefit SOURCE OF COVERAGE DETERMINATION COVERAGE SOURCE DETAILS Utah Medicaid Fee Schedule/Benefit Document</p><p>DATE REQUEST RECEIVED DATE SENT FOR MEDICAL REVIEW UM STAFF MEMBER SUBMITTING / / / / REASON FOR MEDICAL REVIEW CRITERIA USED BY UM STAFF CRITERIA SUBSET USED Criteria Not Met INTERQUAL INDIVIDUAL NEEDS ASSESSMENT IF APPLICABLE (ie age, co-morbidity, complicaionts, treatment progress, psycho-social situation, home environment, local delivery system):</p><p>COMMENTS:</p><p>CATALOG OF SUPPORTING CLINICAL DOCUMENTATION SUBMITTED Prior Auth Request Form Hospital Discharge Summary dated: Hospital Notes dated: Practitioner/clinic notes dated: Therapy evaluation dated: Letter of medical necessity dated: Provider prescription dated: Imaging studies dated: Synagis auth request form dated: Other documents (specify): </p><p>REVIEWER Gary Call, M.D. CRITERIA USED FOR REVIEW CRITERIA SUBSETS REVIEWED INTERQUAL MEDICAL REVIEW DECISION COMMENTS AUTHORIZE IF DENIAL, SPECIFIC REASON (to be included in denial notice) Enclose copy of criteria with denial notice to provider Not applicable, service is authorized COMMENTS TO BE INCLUDED IN DENIAL NOTICE:</p><p>DECISION DATE REVIEWER SIGNATURE: / / </p><p>ACTIVITY DATE STAFF TIME FRAME REVIEW PROVIDER VERBAL NOTIFICATION PROVIDER WRITTEN NOTIFICATION SERVICE PROVIDER WRITTEN NOTIFICATION MEMBER WRITTEN NOTIFICATION Documentation of assistance in transitions to other care if applicable: </p><p>MHU MEDICAL REVIEW REQUEST FORM 1/05 VERSION</p><p>MOLINA HEALTHCARE OF UTAH MEDICAL REVIEW REQUEST FORM</p><p>MHU MEDICAL REVIEW REQUEST FORM 1/05 VERSION </p>