OR HMO Fax Cover Sheet – Request for Authorization of Post-stabilization Services
Last Updated: December 30, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: OR HMO
REQUEST FOR AUTHORIZATION TO PROVIDE POST-STABILIZATION SERVICES : Federal regulations require that you (1) provide post-stabilization authorization, or (2) enter into a disagreement of care and arrange for the transfer of the patient within 60 minutes from receipt of this notification, per 42 CFR §422.113 and 42 CFR §... View more
PA HMO Affidavit – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Interest Owed on Late Claims Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 40 P.S §991.2166(b), which... View more
PA HMO Affidavit – Maternity Coverage
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Maternity Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 31 Pa. Code §154.12(a), which states: (a)... View more
PA HMO Affidavit – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Medical Necessity – Competent Reviewer Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 28 Pa. Code §9.705(c)(3)(i), which state:... View more
PA HMO Affidavit – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Emergency and Urgently Needed Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 28 Pa. Code §9.672(b) which... View more
PA HMO Affidavit – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Timeframes for Authorization Requests – Non-Urgent Health Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 28 Pa.... View more
PA HMO Affidavit – Notice Requirements for Adverse Determinations
Last Updated: October 15, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Notice Requirements for Adverse Determinations Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 28 Pa. Code §9.705(c)(1)(vi), which... View more
PA HMO Affidavit – Poststabilization Timeframe
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Poststabilization Care Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 28 Pa. Code §9.753(a), which state: (a) ... View more
PA HMO Affidavit – Refund Recoupment
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Refund Recoupment Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 40 PA.C.S §3803(a-b), which states: (a) General rule.–Except... View more
PA HMO Affidavit – Untimely Payment
Last Updated: October 15, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Prompt Payment to Providers Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 40 P.S §991.2166(a), which states:... View more