Retro Review Request Form

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* Required Field

Enter Patient Information

  • Facility:
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Group ID: *
  • Date of Service/Admission Date: *
  • ICD-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters with NO decimals
    Codes must be 3 - 8 characters and no decimals.

* Required Field

Enter Provider Information

  • Provider ID OR NPI: *
  •  
    • I am an Admitting Physician
    • I am an Attending Physician
  • Admitting Physician's Name:
  • Admitting Physician's Address:
  • Admitting Physician's City:
  • Admitting Physician's State:
  • Admitting Physician's Zip:
  • Admitting Physician's Email Address:
  • Admitting Physician's Phone No:
  • Admitting Physician's Fax No:
  • Attending Physician's Name:
  • Servicing Attending's Address:
  • Attending Physician's City:
  • Attending Physician's State:
  • Attending Physician's Zip:
  • Attending Physician's Email Address:
  • Attending Physician's Phone No:
  • Attending Physician's Fax No:
  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address:
  • Contact Phone No:
  • Contact Phone Ext:
  • Contact Fax No:

You are required to include and attach supporting documentation for all of the following:

Attach the latest History and Physical documentation: *

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







Include the Discharge Summary: *

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







If an extended stay (10 or more days) include progress notes weekly (explain): *

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







  • Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please print and fax it to (816) 995-1580.

Cancel

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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