Forms Library

Section Banner Image

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 services that do require pre-authorization, you can submit your request via our portal at MHNetProvider.com. To view the information we request, below you'll find the Standard OTR and specific versions for Pennsylvania Substance Abuse, Kentucky CMHCs, Kentucky Outpatient Services (non-CMHC), 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, 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, 1.855.995.4086. ALL OTRs SHOULD BE SUBMITTED VIA OUR PORTAL AT MHNetProvider.com.

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 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
Uniform Treatment Plan Form
PDF
for the State of Maryland
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 and TMS Forms

ECT Prospective Review
PDF
Used to request prospective ECT services. To initiate a Prospective request, complete the “ECT Prospective Request” form and attach the Comprehensive Evaluation/required clinical information to support the current ECT request. For Commercial and Medicare IP ECT: Please contact the assigned Utilization Manager for the fax number to submit the completed form and required documentation. Effective 01/01/2016: MHNet no longer requires authorization for OP ECT. Note: retrospective requests and appeals are submitted to the Appeals Dept for review. Commercial and Medicare Criteria
TMS Prospective Review
PDF
Used to request prospective TMS services for an eligible policy (eligibility can be verified via the link below). To initiate a Prospective request for an eligible policy, 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:


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

MHNet Provider

Manage all your MHNet needs at our secure, one-stop, multi-functional provider portal.

 

Login or Register Now


Get Adobe Reader

© Copyright 2016 MHNet Specialty Services, LLC. All rights reserved