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OTR Forms

We've made changes to the authorization requirements for Commercial and Medicare members. Pre-authorization is not required for standard outpatient services. Please go to our Outpatient Auth section for all the details, including a list of codes that do require pre-authorization. For the limited services that do require pre-authorization, we've specialized forms to request pre-certification.

Below you'll find the OTRs for:

  • Autism/ABA treatment
  • Psychological testing
  • Neuro-psychological testing
  • TMS

Provider Demographic Changes

We appreciate your assistance in keeping MHNet's referral database updated so we can send you referrals! If you need to change your address, name and/or TIN, please complete this Provider Information Change Request Form  so we can properly update your information in all our systems. If you're changing your 'pay to' address, TIN or name, we also need your new W-9 form or you can complete the W-9 substitution area of the form. You can also call Provider Relations directly at 1.855.995.4086, option #5, to request the changes.

It's also helpful to know your areas of specialty, ages treated, etc. so we can make appropriate referrals to you. To update this information, please complete the Sub-Specialty Questionnaire and fax it to 1.724.741.4553, Attn: Provider Relations. For changes to just your phone/fax number, email or areas of practice specialties, you can simply call Provider Relations directly at 1.855.995.4086, option #5, to request these changes.

Additional Forms

Below you'll also find forms used by providers for various needs, including claims.

Outpatient Treatment Request Forms

Autism OTR Form
PDF
Precertification for Psychological Testing Form
PDF
Precertification for Neuropsychological Testing Form
PDF


TMS Form

TMS Prospective Review
PDF
MHNet now covers TMS (CPT codes 90867, 90868, 90869) as a standard benefit. From now until October 31, 2016, no pre-authorization is required. As of November 1, 2016, pre-authorization will be required for TMS treatment. To initiate a Prospective, complete the “TMS Prospective Request” form and attach the Comprehensive Evaluation/required clinical information to support the current TMS request. Please submit the completed form and required documentation, via fax, to: 1.724.741.4554. Note: retrospective requests and appeals are submitted to the Appeals Dept for review.

Links to verify Benefit Eligibility and Medical Necessity Criteria:


Provider Forms

Provider Information Change Request Form
PDF
Use for any changes to your provider demographic information, including Address, TIN, Phone/Fax, and Name. All 'pay to' address and name changes require your updated W-9. If you choose to use the substitute W-9 section of the Provider Information Change Request Form, a separate W-9 is not necessary.
W-9
PDF
All 'pay to' address and name changes require your updated W-9. If you choose to use the substitute W-9 section of the Provider Information Change Request Form, a separate W-9 is not necessary.
Sub-Specialty Questionnaire
PDF
If your areas of specialty, ages treated or languages spoken have changed, please complete the Sub-Specialty Questionnaire.
Authorization to Release Confidential Information
PDF
Authorization Release: Standard Appeal
PDF
This is the only form approved for use when members want to designate an alternate person or entity to appeal on their behalf.
OON Provider Claims
PDF
CMS-1500 Form
PDF
CMS recommends the purchase of official, pre-printed forms from an authorized vendor.
CMS-1450 [UB-04] Form
PDF
CMS recommends the purchase of official, pre-printed forms from an authorized vendor.
Remittance Advice Summary
PDF
"How to Read" document gives detailed explanations


Referral Form

Care Management/Complex Case Management Referral Form
PDF
Form to complete to refer member for Care Management or Complex Case Management Services

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