CLINICAL NOTIFICATION FORM
FAX TO: 260-469-3014
Date: / Agreement Number:Plan Name: / Member Name
Agreement Period: / Patient Name:
Member Type: / Retention: / Member Number:
$ / Patient Date of Birth: _____/_____/_____
Amount of eligible expenses paid to date: $______
Professional $______Hospital $______
Other $______
Total amount of claim expected: $______
Dates of service: From: ____/____/_____ To: ____/_____/_____ / If a bill for services has been received:
Do billed charges exceed R&C? Y N
Are there questionable charges? Y N
If yes, please explain: ______
______
Diagnosis: ______
Prognosis and current
Treatment plan:______
If inpatient (acute, LTAC), provide name and location of facility
______
Is the patient in-network?
If not, have you negotiated a rate?
Negotiated rate______
Expected LOS ______/ Y N
Y N / If member is receiving high cost drugs:
Name of drug ______
Frequency ______
Expected cost per month ______
Drug distributor used ______
Is the member receiving dialysis? / Y N
Is the dialysis center in-network? / Y N
If not, have you negotiated a rate? / Y N
Negotiated rate ______
Dialysis cost per month $ ______
Has member been referred for transplant? / Y N
If not, why? ______
Dialysis start date ______/ Is the member receiving services out your
service area not discussed elsewhere? / Y N
If yes, have you negotiated a rate? / Y N
Negotiated rate ______
Type of services: ______
Is outside vendor performing management services?
Y N Name ______
Is the member in a NICU? / Y N
Is the NICU in-network? / Y N
If not, have you negotiated a rate? / Y N
Negotiated rate ______
Expected LOS ______/ Form completed by:
Name: ______
Title: ______Phone______
Email address ______
How can Summit ReSources assist you in managing this case:
Claim Repricingo Bill Negotiation o Bill Audito Transplant Network o LVAD o Congenital Heart o
Dialysis Negotiation o Dialysis Bill Review o Perinatal or Neonatal Case Managemento Physician Consult/Reviewo
Pharmacy AssistanceoAir Ambulance Negotiation or Bill Review o Clinical Research o