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OTR Forms

Effective January 1, 2014, MHNet has made changes to the authorization requirements for Commercial members. Please go to our Outpatient Auth section to get all the details!

Our latest Outpatient Treatment Report (OTR) forms to align with the changes made in DSM-V are now available! Below you will find the Standard OTR and specific versions for Pennsylvania Substance Abuse, Kentucky CMHCs, Kentucky Outpatient Services (non-CMHC), Florida Medicaid, and Autism Services. There is one exception: for all Maryland providers, please continue to use your mandated State of Maryland Uniform Treatment Plan Form to request outpatient authorizations. The new Standard OTR does not replace any mandated form (e.g. Maryland) or specialized OTR forms (e.g. the PA Substance Abuse OTR, the KY CMHCs OTR, the FL Medicaid OTR, or the Autism OTR). For questions on the OTR form, please call your National Service Center (number on the back of the member's ID card) or Provider Relations at our direct, toll-free number, 855.995.4086.

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 are 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 is 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 will also find forms used for the Authorization to Release Confidential Information, Precert for Psych and Neuro-Psych Testing, OON Provider Claims, CMS 1500 form, UB-04 form, and how to read a Remittance Advice.

Outpatient Treatment Records

Standard OTR Form
PDF
Pennsylvania Substance Abuse OTR Form
PDF
CoventryCares of Kentucky OTR Form
PDF
for Kentucky CMHC providers
CoventryCares of Kentucky Standard OTR Form
PDF
for Kentucky individual/group providers
Autism OTR Form
PDF
OTR Instructions and Hints


Referral Forms

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


ECT Forms

ECT Initial Review
PDF
ECT Concurrent Review
PDF
TMS Authorization Request
PDF


Additional 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.
Precertification for Psychological Testing Form
pdf
Precertification for Neuropsychological Testing Form
pdf
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

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