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For Out-of-network providers, MEGA will reimburse 75% of the Usual and Customary fee for sessions 1-40 (and 60% for sessions thereafter). For the first 6 sessions, they will do this routinely. However, to get reimbursement for sessions beyond that, a simple precertification process is required, described below.
1. Your therapist needs to complete the Questionnaire below, and fax it between the 6th and 7th session. (Fax to 216-514-0706; Attn: Mary Anne Auner). The answers to the questions can also be provided over the phone to Mary Anne Auner (call 216-514-1451 between 8:30-4:30).
2. If faxed, the therapist can request how he/she wants confirmation of how many more sessions are granted (confirmation can be by phone and fax; default is via mail).
3. Your therapist will then be told how much time is certified (e.g. 3 months). At the end of that period, your therapist is required to call in again with a briefer update (e.g. how much more time is needed, etc) to seek additional sessions.
Georgetown University OP Mental Nervous Precert Questionnaire
Provider name:
Provider address/phone:
Tax ID #:
Student Name:
Student ID Number:
Student address/phone number:
Student DOB:
Medical Information:
Axis I - Diagnosis/ICD9 code:
Axis II - 2ndary diagnosis if applicable:
Axis III - Does the patient have a current general medical condition that is potentially relevant to the understanding or management of dx?s in Axis I & II?: No ____ Yes ____
Axis IV- Severity of current psychosocial stressors: Severe__ Moderate__ Mild__ None_____
Axis V ? GAF Score: Score at 1st session ____ Current Score ___
Current Medications of psych dx:
Presence of symptoms:
Suicidal ideation___
Homicidal Ideation___
Self-injurious behavior___
Substance abuse___
Start of initial treatment:
Appointment date of 7th visit for student:
Treating CPT code:
Frequency of visits:
Prognosis limited to the estimated time during which treatment might continue:
If you feel that any of this information violates any applicable statutes, feel free not to address that particular area.
Fax: Attn Mary Anne Auner (216-514-0706) or phone at (216-514-1451)
Revised 9/19/06
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