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Provider Initiated Notice - Adverse Action

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					Provider Initiated Notice - Adverse Action
(Please Print All Information) Provider Name: Address: Telephone: ( Contact Name: ) , City Fax: ( Telephone: ( ) ) Ext , Premier TBH TBH – East AmeriGroup N/A Date of Request: / /

, TN Zip Code:

Attending Physician/Treating Practitioner - Name/Credential: Enrollee Name: MCO/BHO:

AmeriChoice SSN: Address: Telephone: ( Admission Date: ) / / OR Referral Date: / / DOB: / , City / CRG/TPG:

, TN Zip Code:

Discharging Level of Care: Inpatient psych/dual Inpatient Detox Inpatient Rehab Subacute Residential Treatment Supervised Residential PHP/Psych PHP/A&D IOP/A&D IOP/Psych / Reduction / Discharge/Termination CTT CCFT PACT

Case Management Medication Management Outpatient Therapy Other Outpatient:

Date of Anticipated Adverse Action: Request For
1

Delay

Suspension

AMA ( STOP HERE. No further information is needed. Go to last [staff name/signature] field.) Transfer - Same LOC: Provider Name () If Delay or Suspension, service will be available (mm/dd/yy): / / Time: am : pm For LOC Type:

Explain action being taken to remedy access problem:

If Reduction, state how often will the consumer be seen:

1

For inpatient levels of care, this form must be submitted one (1) business day prior to the proposed adverse action date. For outpatient levels of care, this form must be submitted eight (8) calendar days prior to the proposed adverse action date.

PIN For ANY Adverse Action, provide reasons for the proposed action—based on specific facts that are personal to the Enrollee—as to why the Enrollee no longer meets medical necessity criteria:

Page 2

AND, list the specific clinical documentation used to support your decision (include dates of service):

DRAFT discharge summary attached Recommended Level of Care: Inpt Rehab Subacute Residential/Psych Supervised Treatment PHP/Psych PHP/A&D IOP/A&D IOP/Psych

– or –

Discharge plan as follows:

CTT

CCFT

PACT

Case Management Medication Management Outpatient Therapy Other Outpatient, specify:

Discharge to Jail ( STOP HERE. Go to last [staff name/signature] field.) Aftercare Appointments: Provider Name / Address / Telephone Number Service Type / Practitioner Name Name: Street: Service: City: Practitioner: T: ( ST: ) Zip Code: Appointment Date/Time / : / am pm

Name: Street: Service: Name: Street: Service: City: City:

T: ( ST: Practitioner: T: ( ST: Practitioner:

)

Zip Code:

/ :

/ am pm

)

Zip Code:

/ :

/ am pm

Name: Street: Service: City:

T: ( ST: Practitioner:

)

Zip Code:

/ :

/ am pm

PIN Name: Street: Service: City: Practitioner: T: ( ST: ) Zip Code: / : / am pm

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Effective date of discharge plan:

/

/

The information above is correct to the best of my knowledge. I give my permission for the MCO/BHO to notify the member of this information on my behalf. Staff Name/Credential (printed): Staff Signature:      Title: Date: / /

Please fax this form to the appropriate MCO/BHO at: Magellan (TBH, TBH-East, and Premier) 1-800-325-7868 AmeriChoice 1-888-785-1434 AmeriGroup 1-866-920-6006
   
(Revised 10/22/08)

VSHP / Value Options 1-800-292-5311




				
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