New Hampshire Referral Form
1
2
Date_____________________________
2a. Patient Name _______________________________________________________________
2b. Name of Insurance Carrier____________________________________________________
HMO
POS
Other
2c. Patient Insurance ID #________________________________________________________
2d. Patient DOB_____________________________________________ 2g. Emergent (within 48 hours)
2e. Reason for Referral
2h. Out-of-Plan (requires 14 days notice unless ER)
or ICD-9 Code___________________________________________
2i. ER Visit (date) ______________________________
2f. Start Date _______________ Expiration Date _______________
3
Referring Physician:
Referred To:
3a. Full Name ______________________________________________
3h. Full Name ____________________________________
3b. Telephone ______________________________________________
3i. Full Address __________________________________
3c. Fax or E-mail ____________________________________________
____________________________________________
3d. Provider ID # ____________________________________________
____________________________________________
3e. Provider Signature_______________________________________
3j. Telephone____________________________________
3f. PHO ID_________________________________________________
3k. Fax or E-mail___________________________________________
____________________________________________________
3l. Provider ID #__________________________________
3g. Lab Vendor _________________________________________
3m. Hospital/Facility to be used
4
Office Visits:
Rehabilitation:
(check as appropriate)
4a. Consult/recommendation only________________________________
4b. Treatment _____________________________________________
specify exact number visits
4f.
OT
Other
4g.
Physical Therapy:
Treatment
4d. Necessary diagnostic studies:
Other
CT Scan
Bone Scan
Cardiac
Evaluation or Education
4c. Other ______________________________________________________
MRI
Speech
Hospital/Facility:
________________________________________________
4h.
Inpatient
Day surgery
Observation
4e. Prolonged treatment ____________________________________
specify exact number visits
4i. Comments _______________________________________________________________________________________________________________
5
This referral is not an authorization or guarantee of coverage.
Insurer and PCP must be contacted prior to any hospital admission.
Insurer will not be responsible for payment of non-covered services, even
with PCP referral.
Generally, referrals are valid for 6 months from the date on referral form,
unless otherwise limited by PCP’s direction. Individual plans vary.
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HPHC Only
HCFA 1500
By accepting this referral, the provider may be required to accept payment
based on insurer’s applicable fee schedule.
HMO services not authorized by the PCP are not covered.
HMO benefits will generally only be paid for Out-of-Plan services with
preauthorization by insurer’s Medical Director.
___________________________________________________________________
Medical Director’s Authorized Signature
To be completed by HPHC
HCFA Box 17 ___________________________________
UB-92 Please include the following information:
HCFA Box 17a __________________________________
UB-92 Box 63 ____________________________________
HCFA Box 23 ___________________________________
0850 Rev. (3/00)
570296
White: Insurer
Yellow: Provider
Pink: Specialty Care Provider
Goldenrod: Patient (If appropriate)
Anthem Blue Cross and Blue Shield/
Matthew Thornton Health Plan
3000 Goffs Falls Road
Manchester, NH 03111-0001
CIGNA HealthCare of New Hampshire
PO Box 2041
Concord, NH 03302-2041
Harvard Pilgrim Health Care of NE —
For resubmission of all paper claims please see
HPHC specific directions in your manual
Harvard Pilgrim Health Care of NE Commercial
Product — First Copy HCFA 1500
(NOT including DME, Early Intervention,
hemodialysis, high-tech therapy, IVF, SNF or VNA)
Harvard Pilgrim Health Care of NE
PO Box 699213
Quincy, MA 02269-9213
Harvard Pilgrim Health Care of NE Commercial
Product — First Copy HCFA 1500, UB92
(Specifically For DME, Early Intervention,
hemodialysis, high-tech therapy, IVF, SNF or VNA)
Harvard Pilgrim Health Care of NE
PO Box 699216
Quincy, MA 02269-9216
Harvard Pilgrim Health Care of NE Commercial
Product — First Copy UB92
(NOT Including DME, Early Intervention,
hemodialysis, high-tech therapy, IVF, SNF or VNA)
Harvard Pilgrim Health Care of NE
PO Box 699176
Quincy, MA 02269-9176
Harvard Pilgrim Health Care of NE Senior
Product — First Copy HCFA 1500, UB92
(Including DME, Early Intervention, hemodialysis,
high-tech therapy, IVF, SNF or VNA)
Harvard Pilgrim Health Care of NE
PO Box 699201
Quincy, MA 02269-9201
INSTRUCTIONS FOR COMPLETION OF THE STANDARD REFERRAL FORM
1.
Date referral written (backdate if after date of services)
3h. Full name of provider that patient is being referred to
2a. Full name of patient being referred, e.g. John A. Smith, Jr.
3i. Full address of provider that patient is being referred to
2b. Patient’s insurance carrier’s name, e.g. Cigna, Anthem
Blue Cross and Blue Shield, etc.
Check if plan is a Health Maintenance Organization plan,
a Point of Service plan or Other
3j. Telephone number of provider that patient is being referred
to ( _ _ _ ) _ _ _ - _ _ _ _
2c. Patient’s insurance carrier identification full number,
including prefix and suffix, e.g. YGG01122334400
2d. Patient’s date of birth, e.g. 01/02/56 (must be in this format
_ _ / _ _ /_ _ )
2e. Diagnosis, e.g. abdominal pain or ICD-9 code
2f. Start and end date which the referral authorization covers.
2g. Check box if referral is needed emergently
2h. Check box if referral is to provider/facility that is Out of Plan
OR Tertiary for insurance carrier
2i. If referral is for Emergency Room visit, fill in date of service
3k. Fax and/or E-mail address of provider that patient is being
referred to
3l. If required, provider’s insurance carrier identification number
3m. Name of hospital or facility that is to be used
(some insurance
carriers require that certain facilities be used)
4a. Check if referral is for a consult or recommendation — one
visit only
4b. Indicate number of visits for treatment
4c. Other pertinent information
4d. Check one or more of specialized diagnostic tests
(precertify if necessary)
4e. Prolonged treatment, e.g. allergy injections, PT, oncology, etc.
3a. Full name of referring provider (usually Primary Care
Provider)
4f. Check one or more of rehabilitation services required
3b. Fill in telephone number of referring provider, including area
code, e.g. (603) 321-1234 ( _ _ _ ) _ _ _-_ _ _ _
4g. Check “Evaluation or Education” (generally 1– 2 visits only)
or “Treatment” for Physicial Therapy (check for the maximum
allowable benefits under patient’s insurance carrier policy)
3c. Fill in fax number or E-mail address if applicable
3d. If required, fill in referring provider’s insurance carrier
identification number
3e. Signature of referring provider
3f. PHO ID number (if applicable)
3g. Name of laboratory vendor that is to be used, e.g. Path Lab
(some insurance carriers require certain laboratories to be used)
4h. Check Hospital/Facility (if known may check here)
4i. Use for special comments, requests, circumstances, etc.
5.
For patient and provider to read
6.
HPHC to complete and forward to Speciality Care Provider