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D. Office Contact Name Provider Name Phone - Fax - Services to be provided at Office 11 Inpatient Stay 21 Outpatient Hospital 22 DIRECT REFERRALS ONLY CHECK ONE Well Woman Exam REQUESTED FACILITY ANY FOLLOW VISITS OR PROCEDURES MUST BE PRE-AUTHORIZED BY NMM 99385 age 18-39 99386 age 40-69 99396 age 71 and over Pregnant OB Care full term - 59400 Mammography G0202 40 50 years eligible every 2 years Chest Long Bone or KUB X- Rays indicate CPT PATIENT REQUEST M. NETWORK MEDICAL MANAGEMENT INC...

How to fill out network medical management form

How to fill out network medical management authorization:

1. Obtain the form: Begin by getting a copy of the network medical management authorization form. This can usually be acquired from your healthcare provider's office or insurance company.
2. Provide personal information: Fill in your personal details such as your full name, date of birth, address, and contact information. Make sure to enter accurate information to avoid any issues with processing.
3. Specify the medical condition: Indicate the specific medical condition for which you are seeking network medical management. This could be a chronic illness, surgery, or specialized treatment. Clearly describe the condition and any relevant details.
4. State the requested services: Detail the specific medical services or procedures you are requesting authorization for. This could include appointments with specialists, diagnostic tests, surgeries, or prescription medications. Be as specific as possible to ensure accurate authorization.
5. Attach supporting documents: Include any supporting documents that may be required for the request. This could be medical records, test results, or a letter of medical necessity from your healthcare provider. Ensure that all attachments are clear and legible.
6. Sign and date the form: Once you have completed filling out the form, sign and date it to verify the information provided. Failure to sign the form may result in a delay in processing.

Who needs network medical management authorization:

1. Patients requiring specialized care: Individuals with complex medical conditions or who need specialized treatments may need network medical management authorization. This ensures that they receive the appropriate healthcare services within the network.
2. Insurance plan participants: Individuals who have an insurance plan that requires authorization for certain medical services may need network medical management authorization. This helps the insurance company manage healthcare utilization and costs.
3. Healthcare providers: Healthcare providers may also need network medical management authorization to ensure that they are able to provide specific services to patients within their network. This allows for coordination of care and proper utilization of resources.

In summary, filling out network medical management authorization involves obtaining the form, providing personal information, specifying the medical condition and requested services, attaching supporting documents, and signing the form. This authorization is typically needed by patients requiring specialized care, insurance plan participants, and healthcare providers.

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What is network medical management authorization?

Network medical management authorization is a process used by healthcare providers to obtain approval from a health insurance plan for specific medical services, procedures, or treatments prior to their delivery.

Who is required to file network medical management authorization?

Typically, healthcare providers or medical facilities seeking insurance reimbursement for services rendered to patients are required to file network medical management authorization.

How to fill out network medical management authorization?

To fill out network medical management authorization, healthcare providers must complete the authorization form with necessary patient information, specific medical details, the requested service, and any relevant clinical documentation.

What is the purpose of network medical management authorization?

The purpose of network medical management authorization is to ensure that the medical services requested are medically necessary and covered under the patient's health plan, ultimately helping to manage healthcare costs.

What information must be reported on network medical management authorization?

The information that must be reported on network medical management authorization includes patient demographics, insurance details, the specific procedure or treatment requested, medical necessity information, and any supporting clinical documentation.