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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 1^st 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 7^th 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