Patient Name
Eval/1st visit date (mm/dd/yyyy) for this episode
Medical Necessity Review Form - PT OT AT for ORTHOPEDIC conditions - 07/07/2020
Page 1 of 1
From (mm/dd/yyyy)
MEDICAL NECESSITY REVIEW FORM
PT OT AT-New or Continuing Care for ORTHOPEDIC conditions
For questions, please call ASH at 800.972.4226
American Specialty Health (ASH)
P.O. Box 509077, San Diego, CA 92150-9077
Fax: 877.248.2746
FOR ASH
USE ONLY
ASH MNR FORM #
RECEIVED DATE
ASH CLINICAL QUALITY EVALUATOR
Last First Initial
Gender
M
F
Birthdate (mm/dd/yyyy)
Patient ID #
Subscriber Name Subscriber ID #
Is This?
Work Related
Auto Related
Health Plan
Primary
Secondary
Employer
Group #
REFERRED BY (if required) Physician Name
Referral DX
FOR OUT-OF-NETWORK PROVIDER ONLY: TIN #
State License #
NPI Number Type 1 (Individual)
NPI Number Type 2 (Organization)
TREATING PRACTITIONER INFORMATION
PATIENT MAILING ADDRESS AND PHONE NUMBER
Provider (TIN Owner) Name
Treating Therapist
Address
Facility/Clinic Name
Facility/Clinic Address
City/State/Zip
City/State/Zip
Phone Fax
Phone
SERVICES ALREADY RENDERED (Check one)
PT
OT
AT
Response to Care
Total number of visits rendered for this episode
EMG/NCV/Tests and Measures/Other (Describe and Provide CPT codes)
DME/Supports (Describe and Provide HCPC Codes)
ICD-10 / DIAGNOSES (highest level of specificity - Primary Condition(s) an (Pathology codes
(If Post Surgery use appropriate post-surgical ICD-10 code)
1
2
3
4
SERVICES SUBMITTED FOR REVIEW Are services Habilitative?
PT
OT
AT
Through (mm/dd/yyyy) # of Visits
Frequency/dosage of care
Date of Findings Noted Below (mm/dd/yyyy)
Evaluations/Reevaluations being requested during the From and Through dates:
Evaluation
Reevaluation
EMG/NCV/Tests and Measures/Other (Describe and Provide CPT codes, only if requesting)
DME / Supports (Describe and Provide HCPC Codes
Date of Onset/Exacerbation
Chief Complaint(s)
Location of treatment
Cause of Current Episode
Traumatic
Repetitive
Unknown MVA Post-Surgical (date/type)
Stage of Condition
Acute
Sub-acute
Chronic
Occupation
Nature of Condition
Initial Occurrence
Exacerbation
Recurrent / Chronic
Pain (1-10):
Best-
Worst-
Aggravating factors-
Vital Signs: Blood Pressure
Body Morphology
Height
Handedness:
Right Left
Med/Soc Hx / Co-Morbidities (that may affect recovery)
Area/Joint Movement A-ROM R/L P-ROM R/L Strength R/L (0-5) Joint Mobility
Location - Palpation / Swelling
Practitioners are encouraged to submit additional information as necessary to support the intervention / care submitted
Date
Gait/Balance
Special Testing: (e.g., SLR, Ant Drawer, Impingement, Spurling's)
Reflexes:
WNL
Impaired
Myotomes:
WNL
Impaired
Dermatomes:
WNL
Impaired
Functional Outcome Measure(s) Name:
Score - Initial/Previous
Score - Current:
Additional outcome measure Name:
Score - Initial/Previous
Score - Current:
Goals (progress towards or new goals)
Add'l Findings/POC
to support diagnosis:
Weight
Signature by treating practitioner
(Required) _______________________________________________
This submission is for (Check only one. If both services are necessary, please fill out a separate form):
Estimated Discharge Date (Required)(mm/dd/yyyy)
Yes
No
Spine:
CS
T/L
Flexion / Extension
R/L Rotation
R/L Lateral Flexion
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