Frequently Used Forms - Health Plan of Nevada

Transcription

2016 HPN Provider Summary Guide
25-Frequently Used Forms
25.1
25.2
Request for Allowables Form
@YourService Forms
 A. Request Form
 B. Terms of Use Acknowledgement Form
 C. Penalties for Violations of Terms of Use
25.3 Provider Add Request Form
25.4 Health Plan of Nevada Complaint Form
25.5 Health Plan of Nevada Medicaid – SmartChoice/Nevada Check Up Member
Grievance Form
25.6 Medicaid Maternity Risk Screen Form
25.7 Generic Forms
 A. Outpatient Problem List
 B. Medication Flow Sheet
 C. Personal Health and Social History Sheet
25.8 Nevada Universal Prior Authorization and Referral Form
25.9 Health Plan of Nevada Medicaid- SmartChoice/Nevada Check Up Dentures/Partials
Predetermination Checklist
25.10 Claim Reconsideration Request Form
Additional forms applicable to Southern Nevada providers only:
25.11
25.12
25.13
25.14
25.15
25.16
25.17
25.18
25.19
25.20
25.21
25.22
25.23
25.24
25.25
SMA Imaging Services Expectation Sheet
SMA Routine Imaging Services Order Form
SMA Screening Mammography Imaging Services
SMA Diagnostic Mammography Imaging Services
SMA Imaging Order Form for Bone Density (DEXA Scan)
SMA Imaging Services Expectation Sheet – Bone Density (DEXA Scan)
SMA Imaging Order Form for Cat Scan
SMA Imaging Services Expectation Sheet – Cat Scan
SMA Imaging Order Form for FLOURO
SMA Imaging Services Expectation Sheet – Fluoroscopy
SMA Imaging Services Expectation Sheet – HSG
SMA Imaging Services Expectation Sheet – IVP
SMA Imaging Services Expectation Sheet – Myelogram
SMA Ordering Form for Ultrasound
SMA Imaging Services Expectation Sheet - Ultrasound
HPN 2016 Section 25 Frequently Used Forms
25.1
REQUEST FOR ALLOWABLES
(Fax Request to 702-266-8782)
Date:____________________
Tax ID#: ________________________
Provider/Group Name:_____________________________________________________________
Specialty: __________________________________________________________
Contact Name: __________________ Phone#:_________________ Fax#:___________________
E-Mail: _________________________________________________
Contact is from which of the following? ___Billing Service ___ Provider's office ____Other
Type of Code(s): ___ CPT ___ HCPCS ___ ASA
Please put a check mark next to each contracted line of business you are requesting.
___ Health Plan of Nevada (HPN) – Southern NV
___ Senior Dimensions; Medicare
___ Sierra Health & Life (SHL)
___ Sierra Healthcare Options (SHO)
___ Medicaid (SmartChoice/Nevada Check-up)
___ Medicare Advantage PPO (MAPP)
___ Prime Health
___ Worker's Compensation; Sierra at Work (SAW)
___ Health Plan of Nevada (HPN) – Northern NV
___ Northern Nevada Health Network (NNHN)
Requests are limited to a maximum of 40 codes. Requests submitted with more than 40 codes will only
be processed up to the 40th code. Please maintain and use your EOPs for reference.
1.
6.
11.
16.
21.
26.
31.
36.
2.
7.
12.
17.
22.
27.
32.
37.
3.
8.
13.
18.
23.
28.
33.
38.
4.
9.
14.
19.
24.
29.
34.
39.
5.
10.
15.
20.
25.
30.
35.
40.
Please note: Allowable quotes do not guarantee payment. Claim processing is subject to member
eligibility, benefits, claim processing guidelines, and contract limitations.
Network Development & Contracts/ Provider Services
P.O. Box 15645, Las Vegas, NV 89114-5645
Phone: (702) 242-7088 (800) 745-7065 Fax: (702) 242-9124
*Please allow 30 days for processing*
25.2A
@YourService
Administrator Account Request Form
Please complete this form with the information for the individual your office has designated to be an Account
Administrator.
•
The Account Administrator will be responsible for creating profiles, editing profiles, and password
reset of the individual accounts associated with their provider TIN.
•
The Account Administrator will be responsible for ensuring that every employee (“individual account
holder”) has his/her own username and password for HPN/SHL @YourService and signs the
Acknowledgement to Comply with HPN and/or SHL’s @YourService Terms of Use. The signed
Acknowledgements must be retained by the Account Administrator and produced to HPN/SHL upon
request.
•
The Account Administrator will be responsible for notifying HPN/SHL Provider Services at 702-2427088 within 24 hours of designation of a new Account Administrator, an individual account holder’s
termination of employment and if termination of an individual’s account is necessary for any other
reason.
Billing offices must go through their physician office for access. NO EXCEPTIONS
Please complete and fax to (702) 242-9124 Attn: Provider Services
ALL REQUESTED INFORMATION IS REQUIRED
First & Last Name:
Requestor DOB:
Requestor Job Title:
Office Name:
Office Address:
TIN:
E-Mail:
Phone Number:
Fax Number:
As an authorized user of the HPN/SHL @YourService application, the above named organization will be given access to private and confidential
patient and health plan member data for the exclusive purpose of performing their professional responsibilities. The following rules will govern
usage of the system named above at all times:

Usernames and passwords are to be safeguarded. Disclosing the username and password information to anyone for any reason with the
exception of authorized personnel of the entity providing access to the HPN/SHL @YourService application is STRICTLY PROHIBITED.

The private and confidential data within the HPN/SHL @YourService application is to be safeguarded at all times. The HPN/SHL
@YourService application contains information that is confidential and protected from disclosure by law (except for specific legal exception or
with the individual’s authorization). The Privacy Act of 1974, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the
Federal Privacy Rule all protect the confidentiality of all individually identifiable health information.

Use of the HPN/SHL @YourService application is monitored and subject to audit review. Access to private and confidential data within the
HPN/SHL @YourService application is to be limited to only such data as is required to carry out professional responsibilities. Improper
disclosure or access to private and confidential information (obtained through the computer or otherwise) may result in immediate termination of
system access privileges and possible legal action.
HPN/SHL expressly reserves the right to make any and all determinations concerning violation of the rules stated herein. Any determination made
by us will be final and not subject to any formal review or appeal process.
Note: Please allow up to 10 business days for account set-up. The information will be sent to the above listed requestor(s).
25.2B
Acknowledgement to Comply with Health Plan of Nevada, Inc.’s (“HPN”)
and/or Sierra Health and Life Insurance Company, Inc.’s (“SHL”)
@YourService Terms of Use
•
I acknowledge that I am responsible for my unique @YourService User ID (“User ID”) and must not
share or disclose my User ID. I acknowledge that I am responsible for my use of @YourService and
that I may only access @YourService for job-related purposes.
•
I hereby agree, as a condition of access to @YourService, that I will not access my own Protected
Health Information (“PHI”) or that of a family member or co-worker and will not ask a co-worker to do
so either. I agree that I will not access the PHI of any individual without a job-related purpose.
•
I understand that use of the HPN/SHL @YourService application is monitored and subject to audit
review. Access to private and confidential data within the HPN/SHL @YourService application is to
be limited to only such data as is required to carry out professional responsibilities. Improper
disclosure or access to private and confidential information (obtained through the computer or
otherwise) may result in immediate termination of system access privileges and possible legal
action.
•
I understand that access to @YourService is a privilege, which may be revoked at any time at the
sole discretion of HPN or SHL.
•
I also agree to promptly report all violations or suspected violations of these Terms of Use to
HPN/SHL at 702-242-7186.
I have read and agree to comply with the above.
Signature of User:
Date:
Name of User (please print):
Network Contract Provider:
Administrator Name (please print):
Administrator’s Signature:
Date:
25.2C
Penalties for Violations of Health Plan of Nevada, Inc.’s (“HPN”)
and Sierra Health and Life Insurance Company, Inc.’s (“SHL”)
@YourService Terms of Use
1. As stated in the @YourService Terms of Use Acknowledgement Form, @YourService Users
(collectively “Users” and individually a “User”) are prohibited from accessing @YourService for any
purpose that is not job-related. Users are also prohibited from sharing and/or disclosing their unique
@YourService User ID (“User ID”). A violation of the Terms of Use will result in temporary
suspension or termination of system access privileges as outlined below.
(a) Users are prohibited from using @YourService to access their own Protected Health
Information (“PHI”) or that of a family member, co-worker or any other individual other than
for job purposes and must not ask a co-worker to do so either. A violation of this Term will
result in immediate termination of some or all of the User’s system access privileges. If more
than one User was involved, each User’s system access privileges will be terminated.
(b) An initial violation of the Terms of Use by an individual User which upon investigation is found
to have resulted from an honest error made in good faith and that does not constitute a
violation described in (a) above will not result in deactivation of the User’s ID or termination of
the User’s system access privileges. A second violation by the same User will result in
∗
temporary deactivation of the User’s ID, which may not be reactivated for a period of at least
one (1) month. A third violation will result in termination of the User’s system access
privileges.
(c) Each User is required to have his/her own unique @YourService User ID and password.
Users are prohibited from sharing and/or disclosing their User ID. If a User is found to have
shared or disclosed his/her User ID or used another User’s ID, the involved Users’ system
access privileges will be terminated.
2. If an Account Administrator is found to have created an additional User ID or re-activates a User ID
for any User whose system access privileges were temporarily suspended or terminated, the Account
Administrator’s access privileges for creating and editing account profiles will be revoked and the
provider will be required to designate another Account Administrator.
3. If any single User has had more than one violation of the Terms of Use in a calendar year or more
than one User from the same provider office is found to have violated the Terms of Use in a single
quarterly audit period, the provider will be required to submit a Corrective Action Plan (“CAP”) to
HPN/SHL Provider Services which should include, at a minimum, training for all employees on the
@YourService Terms of Use. The provider will be required to submit a brief description of the
training along with a list of all individuals in attendance to Provider Services.
4. If the Account Administrator fails to respond to an audit request within 14 days from the date of the
initial request, the User ID under investigation will be de-activated until a response is received and a
determination is made as to whether or not a violation occurred.
∗
The Account Administrator is solely responsible for requesting reactivation of a User ID from HPN/SHL Provider Services.
25.3
PROVIDER ADD REQUEST
This form must be completed in full before the Credentialing Department can start the credentialing process on the following
provider. The provider must hold a valid license in the State of their primary location. (Please write legibly.)
Provider Name
Last Name
First
ο MD
Title (please check
appropriate box)
ο PAC
ο DO
ο APN
ο DC
Middle
ο DPM
ο CRNA
-- Preceptor’s Name
Social Security #:
NPI #:
Billing Tax ID Number:
Medicaid #:
Effective Date with Group:
Medicare #:
Primary Group/Practice
Name of Group/Practice
ο Full Time
Provider Will Be (please check appropriate box)
Primary Specialty
ο Part Time
ο Per Diem
Additional Specialty
Primary Address
Street
Suite
City
State
Zip
Phone
Street
Suite
City
State
Zip
Phone
Street
Suite
City
State
Zip
Phone
Additional Sites
to Primary Location
Credentialing Contact (please print name):
Phone Number:
E-mail:
Fax Number:
Mailing Address for Credentialing Application (Will be sent to Primary Address listed above it not specified here)
Street
Suite
City
State
Zip
Phone
THANK YOU!
Please return via fax to (702) 266-8809
25.4
HEALTH PLAN OF NEVADA
COMPLAINT FORM
Member/Insured Name:
Member Number:
Date of Birth:
Description of the issue/concern (please include date(s), any known names of individuals
involved; name of facility, if applicable):
Signature
Date
(If signed, a written response will be submitted to the member/insured)
WHEN COMPLETED, THIS FORM SHOULD BE SUBMITTED TO:
COMPANY NAME:
Health Plan of Nevada
DEPARTMENT:
Customer Response and Resolution Department
MAILING ADDRESS:
P.O. Box 15645
Las Vegas, NV 89114-5645
As always, the Member Services Department can be contacted directly by telephone at the following
numbers:
HEALTH PLAN OF NEVADA:
(702) 242-7300 or (800) 777-1840
SENIOR DIMENSIONS:
(702) 242-7301 or (800) 650-6232
SMARTCHOICE/NEVADA CHECK UP
(702) 242-7317 or (800) 962-8074
TTY
711
25.5
MEDICAID - SMART CHOICE/NORTHERN CHOICE/NEVADA CHECK UP
MEMBER GRIEVANCE FORM
Member/Insured Name:
Member Number:
Date of Birth:
Description of the issue/concern (please include date(s), any known names of individuals
involved; name of facility, if applicable):
Signature
Date
(If signed, a written response will be submitted to the member/insured)
WHEN COMPLETED, THIS FORM SHOULD BE SUBMITTED TO:
COMPANY NAME:
Health Plan of Nevada
DEPARTMENT:
Customer Response and Resolution Department
MAILING ADDRESS:
PO Box 14865
As always, the Member Services Department can be contacted directly at 1-800-962-8074.
25.6
MEDICAID MATERNITY RISK SCREEN
The risk screen is designed to identify pregnant women at risk for preterm birth or poor pregnancy outcome. Please check all risks that apply to the
recipient and make the appropriate referral(s).
Patient Name ______________________
EDC
________
Member ID # _________________
Medicaid #__________________
DOB ________
A. MEDICAL
Substance Abuse
1. _____ Hypertension, chronic or preg. induced
8. Alcohol
2. _____ Gestational diabetes/diabetes
9. Cocaine/crack
3. _____ Multiple gestation (twins, triplets)
10. Narcotics/heroin
4. _____ Previous preterm birth < 5 ½ lbs.
11. Marijuana/hashish
5. _____ Advanced maternal age, > 35 yrs
12. Sedatives/tranquilzers
6. _____ Medical condition, the severity of which
13. Amphetamines/diet pills
affects pregnancy, document below
# times
days/week
# times
days/week
14. Inhalents/glue
7. _____ Previous fetal death
15. Tobacco/cigarette
16. Others, please specify
B. SOCIAL
1._____ Teenager 18 yrs or younger
*4._____ Abuse/neglect during pregnancy
2._____ Non compliant with medical directions
or appointments
3._____ Mental retardation or history of
emotional/mental problems
*5._____ Shelter, homeless or migrant
*6._____ Lack of food
C. NUTRITION
1._____ Teenager 18 years or younger
3._____ Poor diet or pica
2._____ Prepregnancy underweight/overweight
inadequate or excessive weight gain
4._____ Obstetrical/Medical condition requiring
diet modification, document condition below
REFERRALS AND/OR SERVICE PLAN
1. _____ Care Coordination
2. _____ Smoking Cessation
3. _____ Homemaker
4._____ Nutritional Counseling
7._____ Substance Abuse TX
5._____ Glucose Monitor w/nutrition counseling
6._____ Parenting/Childbirth Classes
8._____ No Care Coordination
PROVIDERS COMMENTS OR SUGGESTIONS _______________________________________
SIGNATURE/TITLE _________________________________ SCREENING DATE ____________
SIGNATURE PRINTED ______________________________ PROVIDER # _________________
Office Contact
Phone #
Fax #
Once the form has been completed, please fax it to HPN’s Obstetrical Case Management Team, at (702) 8381444
*Assist Recipient in contacting Appropriate Agencies for Care Coordination of Non-Covered/Carved –Out Plan Services or
Community Health Information*
25.7A
25.7A – Cont’d
25.7B
25.7C
25.7C – Cont’d
25.7C – Cont’d
25.8
25.9
HPN SmartChoice/Nevada Check-up
Dentures/Partials Predetermination Checklist
*Criteria for Partial Denture (codes 5213 and 5214): Missing 4 teeth per arch anterior to the
2nd molars or 4 teeth in a row per arch anterior to the 3rd molars.
 Does the patient have existing dentures/partials?
o If yes, how old are the dentures/partials?
 Has the patient ever had dentures/partials?
o If yes, how old are the dentures/partials?
YES
YES
NO
NO
 No matter the age of existing dentures/partials, why do they need to be replaced and
can they be repaired and/or relined?
 If the treatment plan is for partials, which teeth are missing, which teeth will be extracted
and which teeth will be used as anchor teeth?
 If the treatment plan is for dentures/partials and extractions, list the extractions to be
done by the oral surgeon in remarks or in an attachment. Use the tooth chart on the
claim form to indicate teeth that are already missing.
 Appropriately submit codes for immediate dentures, D5130 and D5140 as opposed to
D5110 and D5120.
 Submit full mouth/comprehensive treatment plans for both arches with diagnostic
duplicated x-rays.
 Restorations on anchor teeth for partials must be specifically indicated; Medicaid does
not cover root canals in any case for recipients 21 and over.
Please include this completed checklist, x-rays, and any other necessary documents when
submitting the predetermination request.
25.10
Single Paper Claim Reconsideration Request Form
This form is to be completed by physicians, hospitals or other health care professionals for paper Claim
Reconsideration Requests for our members.
•
•
Please submit a separate claim reconsideration request form for each request
No new claims should be submitted with this form.
Member Information (Required Information)
Line of Business: (circle one)
HPN
SHL
Senior Dimensions
Medicaid
Member ID and Date of Birth:
Claim #:
Date of Service:
Billed Amount:
Member Last Name
First Name
MI
Expected amount
owed:
Physician/Health Care Professional Information
Tax Identification Number (TIN):
Physician Name/Facility or
other health care professional
(as listed on Provider
Remittance Advice
(PRA)/Explanation of Benefits
(EOB):
Email Address:
Contact Name and
Telephone Number:
Reason for request: (please circle applicable reason)
 Exceeds Timely Filing
 Additional Information
 Coordination of Benefits
 Resubmission of a corrected claim
 Previously processed but rate applied incorrectly resulting in over/underpayment (Network Providers - Check
your fee schedules)
 Prior Authorization/Referral denial
 Resubmission of “Bundled/Incidental” services
 Carve-Outs
(Explain below)
Please include what you are expecting from HPN/SHL regarding this Claim Reconsideration
Comments:
Required attachments:
• Copy of EOP - Claim Form is ONLY required for Corrected Claims Submissions
• Other required attachments as outlined in the Claims Reconsideration Reference Guide
25.11
Imaging Services
To better serve you and your patients, Radiology asks you to please follow these
guidelines when ordering procedures.
All Referral/Orders must be filled out completely to include Date, Patients Name, DOB, Exam type and
Diagnosis.
If a Referral has been written for a Cat Scan, Ultrasound, IVP or Fluoro: Some radiology services over
$200.00 may require prior authorization. Exceptions are HPN, SD, and POS. After calling for prior authorization,
documentation must be included on referral of Authorization # or “none required.”
The referral can then be created in AR or fax (304-7403) to Imaging/Demand Management Department and
patients should be instructed to call 877-5390 to schedule their appointment. Failure to follow the requirements
of this referral process will result in a higher out-of-pocket cost to the patient.
FOR THE FOLLOWING EXAMS:
If you’re Provider has given you a handwritten order. Please bring with you at time of exam.
** FAILURE TO BRING WRITTEN DOCTOR’S ORDERS AT TIME OF EXAM MAY RESULT IN YOUR EXAM
BEING RESCHEDULED.
If an Order has been written for a Mammogram or Breast Ultrasound: Patients can be referred to call
Demand Management Department at 877-5390 to schedule their appointment.
If an Order has been written for a Bone Density (DEXA): Patients can be referred to call
Demand Management Department at 877-5390 to schedule their appointment.
If an Order has been written for a General X-ray: These can be done at all SMA Imaging clinics.
(No appointments needed)
Please provide patients with appropriate Imaging Expectation sheets according to exam being requested.
Listed below are the SMA locations and hours of operation.
SMA Location
Address
Rancho
South Eastern
North Tenaya
Siena
Montecito
West Tropicana
Nellis
Summerlin
West Oakey
888 S. Rancho
4475 S. Eastern
2704 N. Tenaya Way
2845 Siena Heights Dr.
7061 Grand Montecito Park Way
4835 S. Durango Dr.
540 N. Nellis
10105 Banburry Cross Dr.
4750 W Oakey Blvd
270 W. Lake Mead
2210 E. Calvada
Henderson
Pahrump
Telephone Number
877-5125
737-1880
243-8500
617-1227
750-3900
984-5200
459-7424
854-3221
877-5199
677-3720
775-727-6400
24hrs
7am - 8pm
7am - 7pm
8am - 8pm
8am - 8pm
8am - 5pm
8am - 5pm
8am – 4:30pm
8am – 5pm
Days and Hours vary
Days and Hours vary
1. Have patients call Member Services or their Insurance Company to assess if they will have a co-pay,
for Imaging procedure.
2. For release of Southwest Medical Mammo CD/Films, please call 877-5125 option 5, M–F, 8am – 4:30pm.
Mammograms done prior to 2012, please allow 3-5 business days for processing.
Mammo films to be picked up at 888 S. Rancho ONLY
3. CD of digital images will be burned upon arrival at any SMA Imaging Clinic. Hard copy images will be printed
per Providers written request. Please allow 30 minutes for processing.
5. We need a letter & copy of ID from Patient giving permission to family or friend to release films or CD.
PD-0815 (04/16)
25.12
ROUTINE Imaging Services Order
All orders must be filled out completely to include PATIENT’S NAME, DOB, EXAM TYPE and DIAGNOSIS.
PATIENT’S NAME:
DATE OF BIRTH:
PATIENT’S PHONE #:
/
/
PATIENT’S MEMBER #:
SMA MRN:
REQUESTING PROVIDER:
REQUESTING PROVIDER’S ADDRESS:
REQUESTING PROVIDER’S PHONE:
CONTACT PHONE:
CC PROVIDER:
CONTACT PERSON:
DIAGNOSIS AND CLINICAL INFORMATION
REPORT ONLY
CALL STAT REPORT – PH#
FAX STAT REPORT – FAX#
ICD10 CODE(S):
Please Circle:
SEND CD OF IMAGES WITH PATIENT
LEFT
Abdomen 1V
Abdomen 3V
Ankle
C-Spine
RIGHT
Chest
Clavicle
Elbow
Femur
Finger
Foot
Forearm
Hand
BILATERAL
Hip
Humerus
Knee
L-Spine
Ribs
Shoulder
T-Spine
Tib/Fib
Pelvis
Wrist
Other/Special Instructions
** PLEASE BRING THIS WRITTEN DOCTOR’S ORDERS AT TIME OF EXAM. **
SMA Location
Address
Rancho
South Eastern
North Tenaya
Siena
Montecito
West Tropicana
Nellis
Summerlin
West Oakey
888 S. Rancho
4475 S. Eastern
2704 N. Tenaya Way
7061 Grand Montecito Pkwy.
4835 S. Durango Dr.
540 N. Nellis
4750 W Oakey Blvd.
270 W. Lake Mead
2210 E. Calvada Blvd.
Henderson
Pahrump
Physician Signature:
CD-7459 (04/16)
Telephone Number
877-5125
737-1880
243-8434
617-1227
750-3900
984-5200
459-7424
854-3221
877-5199
677-3720
775-727-6400
24hrs
7am - 8pm
7am - 7pm
8am - 8pm
8am - 8pm
8am - 5pm
8am - 5pm
8am - 5pm
8am - 5pm
Days and Hours vary
Days and Hours vary
Date
25.13
Imaging Services – MAMMOGRAM
Appointment Date:
Appointment Time:
Your provider has submitted an order for a mammogram. To schedule or reschedule your exam,
please call, 702-877-5390 Monday through Friday between the hours of 8:00am and 5:00pm.
Listed below are the SMA mammogram locations.
If you’re Provider has given you a handwritten order. Please bring with you at time of exam.
** FAILURE TO BRING WRITTEN DOCTOR’S ORDERS AT TIME OF EXAM MAY RESULT IN YOUR EXAM BEING
RESCHEDULED.
Screening Mammograms
Location of
Appointment
SMA Location
Address
South Eastern
West Tropicana
North Tenaya
Siena
Nellis
Summerlin
West Oakey
4475 S. Eastern
4835 S. Durango Dr.
2704 N. Tenaya Way
540 N. Nellis
4750 W Oakey Blvd
Diagnostic Mammograms / Breast Ultrasound
Location of
Appointment
SMA Location
Address
Rancho
888 S. Rancho Lower Level
To better serve you, Imaging Services asks that you:
1. Arrive 10 minutes prior to your appointment time for paperwork. If you are late for your appointment, you may be
rescheduled.
2. You may have a co-pay for your procedure, please call your insurance company to verify the amount.
3. DO NOT bring children with you to your appointment. We do not have the facilities or the personnel to provide for
their care while your exam is being done.
4. If you have questions about the exam that is being ordered for you please contact your provider directly.
Listed below is the preparation for this exam.
1. Do not use powder, creams, perfumes, deodorant or oils around the breast area or under the arms the
day of the examination.
2. If your last mammogram was digital please bring a CD in place of film.
3. MAMMOGRAM CD/films done out-of-state or at another facility other than SOUTHWEST MEDICAL
ASSOCIATES, must be hand carried the day of your appointment or arrangements made ahead of time
for the CD/films to be mailed to:
Southwest Medical Associates, Inc.
Attn: Rancho Radiology Dept.
P.O Box 15645
4. For release of Southwest Medical Mammo CD/Films, please call 877-5125 option 5, M–F, 8am – 4:30pm.
Mammograms done prior to 2012, please allow 3-5 business days for processing.
Mammo films to be picked up at 888 S. Rancho ONLY
PD-0805 (0416)
25.14
MAMMOGRAM & BREAST ULTRASOUND Imaging Services Order
PATIENT’S NAME:
DATE OF BIRTH:
/
/
SMA MRN:
CONTACT PHONE:
CC PROVIDER:
CONTACT PERSON:
REPORT ONLY
CALL REPORT – PH#
FAX REPORT – FAX#
ICD10 CODE(S):
Patients need to call Demand Management Department at 877-5390 to schedule their appointment.
Please Circle:
LEFT
RIGHT
BILATERAL
MAMMOGRAM, SCREENING
MAMMOGRAM,DIAGNOSTIC
MAMMOGRAM,SCREENING W IMPLANTS
MAMMOGRAM,DIAGNOSTIC W IMPLANTS
US BREAST
Screening Mammograms
SMA Location
Address
South Eastern
North Tenaya
Siena
West Tropicana
Nellis
Summerlin
West Oakey
4475 S. Eastern
2704 N. Tenaya Way
4835 S. Durango Dr.
540 N. Nellis
4750 W Oakey Blvd.
Diagnostic Mammograms / Breast Ultrasound
SMA Location
Address
Rancho
888 S. Rancho
CD-7458 (04/16)
Date
25.15
BONE DENSITY (DEXA) Imaging Services Order
All orders must be filled out completely to include PATIENT’S NAME, DOB, EXAM TYPE and DIAGNOSIS
PATIENTS NAME:
DATE OF BIRTH:
/
/
SMA MRN:
CONTACT PHONE:
CC PROVIDER:
CONTACT PERSON:
REPORT ONLY
CALL REPORT – PH#
ICD10 CODE(S):
FAX REPORT – FAX#
Patients need to call Demand Management Department at 877-5390 to schedule their appointment.
BONE DENSITY (DEXA)
SMA Location
Address
South Eastern
Rancho
Siena
4475 S. Eastern
888 S. Rancho
CD-7456 (11-15)
Date
25.16
Imaging Services – DEXA SCAN – BONE DENSITY
Appointment Date:
Appointment Time:
Your provider has written you an order for a Bone Density exam. To schedule or reschedule
your exam, please call, 702-877-5390 Monday through Friday between the hours of 8:00am
and 5:00pm. Listed below are the SMA locations.
** FAILURE TO BRING WRITTEN DOCTOR’S ORDERS AT TIME OF EXAM MAY RESULT IN YOUR EXAM
BEING RESCHEDULED OR CANCELLED.
Location of
Appointment
SMA Location
Address
Rancho
South Eastern
Siena
888 S. Rancho
(300 lbs and under)
4475 S. Eastern Ave (350 lbs and under)
2845 Siena Heights Dr. (350 lbs and under)
1. Arrive 10 minutes prior to your appointment time for paperwork. If you are late for your
appointment, you may be rescheduled.
2. You may have a co-pay for your procedure, please call your insurance company to verify
the amount.
3. DO NOT bring children with you to your appointment. We do not have the facilities or the
personnel to provide for their care while your exam is being done.
4. If you have questions about the exam that is being ordered for you please contact your
provider directly.
Listed below is the preparation for this exam.
1. Please wear clothing that does not have METAL, ZIPPERS, and BRAS or they will need to
be removed prior to exam.
2. NO MULTIVITAMINS OR ANTACIDS CONTAINING CALCIUM on THE SAME DAY of
EXAM.
3. Take all your other medications as usual.
4. If you have had any x-rays within the past 30 days involving Barium, please make sure this is
scheduled 30 days after any barium study.
5. FEMALE PATIENTS ONLY – If you are still menstruating please schedule your appointment within
2 weeks of your last period.
PD-0810 (12/15)
25.17
CAT SCAN Imaging Services
PATIENT’S NAME:
DATE OF BIRTH:
/
/
SMA MRN:
CONTACT PHONE:
CC PROVIDER:
CONTACT PERSON:
IS THIS A TRANSPLANT PATIENT?
REPORT ONLY
STAT (24hrs.)
Expedited (72hrs)
AT RISK (14 days)
Routine (30 days)
ICD10 CODE(S):
PLEASE INDICATE WHAT EXAM:
EXTREMITY ONLY PLEASE CIRCLE:
LEFT
RIGHT
BILATERAL
CT ABDOMEN
CT HEAD/BRAIN
CT SOFT TISSUE NECK
CT ABD/PELVIS
CT FACIAL
CT C-SPINE
CT CHEST
CT MANDIBLE
CT L-SPINE
CT CHEST/ABDOMEN
CT ORBITS
CT T-SPINE
CT CHEST/ABD/PELVIS
CT IAC/SELLA
CT EXTREMITY LOWER
CT PELVIS
CT SINUS.
CT EXTREMITY UPPER
PLEASE CIRCLE:
WITHOUT CONTRAST
WITH CONTRAST
SMA Location
Rancho
South Eastern
North Tenaya
CD-7455 (11/15)
Address
888 S. Rancho
4475 S. Eastern
2704 N. Tenaya Way
Date
25.18
Imaging Services – CT Scan
Exam:
Location for Exam:
Appointment Date:
888 S. Rancho Dr.
Appointment Time:
4475 S. Eastern
2704 N. Tenaya Way
Your provider will send your referral to the Southwest Medical Associates (SMA) Scheduling department. Please
allow two to three business days for your referral to be processed. To schedule, reschedule or cancel your exam,
please call, 877-5390 Monday through Friday between the hours of 8:00am and 5:00pm.
Bring your most recent films, related to the current problem, which were done at a facility other than Southwest
Medical Associates. They must be hand carried the day of your appointment.
1. Arrive 10 minutes prior to your appointment time for paperwork and check in at the reception desk. If you are
late for your appointment, you may be rescheduled.
2. You may have a co-pay for your procedure, please call your insurance company to verify the cost.
3. DO NOT bring children with you to your appointment. We do not have the facilities or the personnel to
provide for their care while your exam is being done.
If you are a diabetic taking a medication that includes Glucophage/metformin, please contact your
provider regarding your medication, lab work will need to be done 48hrs after your exam. If your exam is
being ordered with IV contrast and you are allergic to iodine, you must contact your provider for specific
instructions regarding your exam.
If you are having an exam that will use IV contrast, you may be required to have a blood test that must be
completed a minimum of 3 days prior to your exam date. This blood test is a BUN and Creatinine and should be
ordered by your provider. Reasons patients must have the blood test:
1. You are 60 years of age or older 2. You have known or potential renal disease. 3. You are a diabetic.
For best results some examinations require the administration of a preparation. Listed below are the
preparations required for these exam types. All oral CT prep solutions can be picked up at any SMA facility.
Failure to prepare may result in rescheduling your appointment. Exams not listed will not require any
preparation.
*CT Scan of the brain, soft tissue of the neck, or the chest (with IV contrast)
1.
2.
3.
4.
Nothing to eat for four (4) hours prior to the exam.
You may have clear liquids up to two (2) hours prior to the exam.
Take prescribed medication (unless instructed otherwise)
Blood work as needed
*CT Scan of the abdomen:
1.
2.
3.
4.
Nothing to eat for four (4) hours prior to the exam.
You may have clear liquids up to two (2) hours prior to the exam.
Take prescribed medication (unless instructed otherwise)
One hour prior to your exam, drink the 1 bottle of CT oral prep.
*CT Scan of the pelvis, or both the abdomen and pelvis:
1.
2.
3.
4.
5.
Nothing to eat four (4) hours prior to the exam.
You may have clear liquids until two (2) hours prior to the exam.
Take prescribed medications (unless instructed otherwise)
Drink one (1) bottle of the CT oral prep, three hours prior to your exam.
Finish drinking the 2nd bottle of the CT oral prep one-hour prior to your exam.
*These exams usually require an intravenous injection of a substance known as, iodine contrast media, which
helps visualize blood vessels and organs
PD-0816 (12/15)
25.19
FLUORO Imaging Services
PATIENT’S NAME:
DATE OF BIRTH:
/
SMA MRN:
CONTACT PHONE:
CC PROVIDER:
CONTACT PERSON:
REPORT ONLY
STAT (24hrs.)
Expedited (72hrs)
AT RISK (14 days)
Routine (30 days)
ICD10 CODE(S):
PLEASE INDICATE WHAT EXAM:
BARIUM ENEMA
MYELOGRAM, CERVICAL
BARIUM ENEMA, AIR CONTRAST
MYELOGRAM, LUMBAR
CYSTOGRAM
MYELOGRAM, THORACIC
CYSTOGRAM, VOIDING
SMALL BOWEL FOLLOW THROUGH
ESOPHAGRAM
UPPER GI
HYSTEROSALPINGOGRAM
UPPER GI AND ESOPHAGRAM
IVP
UPPER GI AND SMALL BOWEL STUDY
SMA Location
Rancho
CD-7453 (11/15)
Address
888 S. Rancho
Date
/
25.20
Imaging Services – Fluoroscopy Exam
Exam:
Appointment Date:
Appointment Time:
Location for Exam: 888 S. Rancho Dr.
Your provider will send your referral to the Southwest Medical Associates (SMA) Scheduling
department. Please allow two to three business days for your referral to be processed. To schedule or
reschedule your exam, please call, 877-5390 Monday through Friday between the hours of 8:00am
and 5:00pm.
Bring your most recent films, related to the current problem, which were done at a facility other than
Southwest Medical Associates. They must be hand carried the day of your appointment.
1. Please check in at the reception desk located in the lobby.
2. Arrive 10 minutes prior to your appointment time for paperwork. If you are late for your appointment,
you may be rescheduled.
4. DO NOT bring children with you to your appointment. We do not have the facilities or the personnel
to provide for their care while your exam is being done.
5. If you have questions about the exam that is being ordered for you please contact your provider
directly.
For best results some examinations require the administration of a preparation. Listed below are the
preparations required for these exam types. Failure to prepare may result in rescheduling your
appointment.
These exams should not be scheduled after 9:00am if you are Diabetic.
Barium Enema (BE)
Your ordering provider will prescribe moviprep for you to pick up from the pharmacy.
Moviprep is a laxative solution that increases the amount of water in the intestinal tract to stimulate
bowel movements
Once your appointment is scheduled pick up your prep
Please take this prep as directed by your ordering provider.
Please complete the entire bowel prep regimen unless otherwise directed by your provider.
Upper GI (UGI), Barium Swallow, Esophogram, Small Bowel Follow Through
Nothing to eat, drink, or smoke after midnight. No breakfast until after the examination is completed.
Small Bowel follow-through exams may take 4 hours or more to complete. Please wear comfortable
shoes.
PD-0811 (02/15)
25.21
Imaging Services – Hysterosalpingogram (HSG) Exam
Exam:
Appointment Date:
Appointment Time:
Location for Exam: 888 S. Rancho Dr.
Your provider will send your referral to the Southwest Medical Associates (SMA) Scheduling department. Please allow
two to three business days for your referral to be processed.
To schedule or reschedule your exam, please call, 877-5390 Monday through Friday between the hours of 8:00am and
5:00pm, on the first day of your menstrual cycle. Essure patients must be scheduled 8 weeks after
Essure procedure.
Bring your most recent films, related to the current problem, which were done at a facility other than Southwest Medical
Associates. They must be hand carried the day of your appointment.
2. Arrive 10 minutes prior to your appointment time for paperwork. If you are late for your appointment, you may be
rescheduled.
4. DO NOT bring children with you to your appointment. We do not have the facilities or the personnel to provide for
their care while your exam is being done.
5. If you have questions about the exam that is being ordered for you, please contact your provider directly.
Listed below is the preparation required for this exam. Failure to prepare will result in rescheduling your appointment.
HSG Appointment: (IF you are still on your menstrual cycle exam cannot be done)
Regular Menstrual cycle:
1.
The exam will be scheduled for 7-10 days, from the 1st day of your menstrual cycle.
2.
Patient must be accompanied by an individual to drive the patient home after the examination is complete.
3.
No sexual intercourse from the 1st day of your menstrual cycle until 24 hours after the exam.
Irregular or No Menstrual cycle: Complete lab work ordered by requesting provider/PCP (Pregnancy test) 2 days prior to
appointment.
1.
No sexual intercourse for 17 consecutive days, day 15 get blood drawn, schedule your exam on day 16 or 17.
Refrain from sexual intercourse from day 1 until 24 hours after the scheduled exam.
2.
Obtain an order from your provider for a serum blood pregnancy test to be done on day 15 depending on the day of the exam
(1 or 2 days prior to scheduled exam).
3.
Exam must be done on day 16 or 17 *No sexual intercourse from day 1 until 24 hours after scheduled exam. **
Essure HSG Appointment:
1.
Please refer to Regular or Irregular Menstrual cycle protocol above.
Please be aware the Exam may take about 1 hour unless Radiologist needs additional Images which may require
additional time.
PD-0798 (01/16)
25.22
Imaging Services – IVP Exam
Location: 888 S. Rancho Dr.
Appointment Date:
Appointment Time:
department. Please allow two to three business days for your referral to be processed. To schedule or
reschedule your exam, please call, 877-5390 Monday through Friday between the hours of 8:00am
and 5:00pm.
Bring your most recent films, related to your current problem, which were done at a facility other than
Southwest Medical Associates. They must be hand carried on the day of your appointment.
you may be rescheduled.
5. If you have questions about the exam that is being ordered for you please contact your provider
directly.
Your ordering provider will prescribe Moviprep for you to pick up from the pharmacy.
Moviprep is a laxative solution that increases the amount of water in the intestinal tract to stimulate
bowel movements
Once your appointment is scheduled pick up your prep
Please take this prep as directed by your ordering provider.
Please complete the entire bowel prep regimen unless otherwise directed by your provider.
You are having an exam that will use IV contrast, you may be required to have a blood test
that must be completed a minimum of 3 days prior to your exam date. This blood test required
is a BUN and Creatinine and should be ordered by your provider. Reasons patients must have
the blood test:
1. You are 60 years of age or older
2. You have known or potential renal disease
3. You are a diabetic
*Failure to complete lab work may result in your appointment being rescheduled*
If you are a diabetic taking a medication that includes Glucophage, and/or you are
allergic to iodine, you must contact your provider for specific instructions regarding
your exam.
PD-0802 (12/15)
25.23
Imaging Services – Myelogram & Post Myelogram CT Scan
Exam:
Appointment Date:
Location for Exam:
Appointment Time:
888 S. Rancho Dr.
department. Please allow two to three business days for your referral to be processed.
To schedule or reschedule your exam, please call, 877-5390 Monday through Friday between the
hours of 8:00am and 5:00pm.
1. Please check in at the cubicles located in the lobby.
you may be rescheduled
5. If you have questions about the exam that is being ordered for you, please contact your provider
directly.
If you are a diabetic taking a medication that includes glucophage, please contact your provider
regarding your medication. Your exam is being ordered with contrast. If you are allergic to iodine,
you must contact your provider for specific instructions regarding your exam.
Listed below is the preparation required for this exam. Failure to prepare may result in rescheduling your
appointment.
Prior to Appointment:
1.
Patient to complete lab work ordered by requesting provider/PCP (PT/PTT/INR/ PLATLETS)
14 days prior to appointment.
2.
Patient to bring Non-SMA images related to the exam on the day of the appointment.
3.
No Blood Thinners (i.e. Aspirin(ASA), Plavix, Coumadin) 7 days prior to appointment.
Day of Appointment:
1.
Patient must have a regular breakfast and drink plenty of fluids prior to appointment.
Nothing to eat or drink after 9:00 a.m. unless diabetic, If diabetic limit intake to clear liquids.
2.
Patient must be accompanied by an individual to drive the patient home after the examination
is complete.
3.
Please be aware the Myelogram and post Myelogram CT may take 2 to 3 hours to complete.
PD-0796 (12/15)
25.24
ULTRASOUND Imaging Services
PATIENT’S NAME:
DATE OF BIRTH:
/
/
SMA MRN:
CC PROVIDER:
CONTACT PHONE:
CONTACT PERSON:
REPORT ONLY
STAT (24hrs.)
Expedited (72hrs)
AT RISK (14 days)
Routine (30 days)
ICD10 CODE(S):
PLEASE INDICATE WHAT EXAM
US ABDOMEN, COMPLETE
US PELVIC & TVAG, COMPLETE
US AORTA, COMPLETE
US TRANSVAGINAL
US GALL BLADDER
US PELVIC TRANSABDOMINAL
US LIVER, COMPLETE
US CAROTID, COMPLETE BILATERAL
US LIVER, VASCULAR ONLY
US RENAL/BLADDER
US THYROID
US SOFT TISSUE NECK/HEAD
US RENAL, VASCULAR ONLY
US MISC for LUMP-VARIOUS BODY PART
US RETROPERITONEAL, BLADDER
US LOWER VENOUS
US TESTICULAR
US UPPER VENOUS
EXTREMITY/VENOUS ONLY Please Circle:
LEFT
RIGHT
SMA Location
888 S. Rancho
4475 S. Eastern
2704 N. Tenaya W ay
Montecito
Summerlin
West Oakey
4750 W Oakey Blvd.
CD-7461 (04/16)
Address
Rancho
South Eastern
North Tenaya
Siena
Date
BILATERAL
25.25
Imaging Services – ULTRASOUND
Exam:
Appointment Date:
Appointment Time:
Your provider will send your referral to the Southwest Medical Associates (SMA) Scheduling department.
Please allow two to three business days for your referral to be processed.
To schedule or reschedule your exam, please call, 877-5390 Monday through Friday between the hours of
8:00am and 5:00pm.
Location of Appointment
SMA Location
Address
Rancho
South Eastern
North Tenaya
Siena
Montecito
Summerlin
West Oakey
888 S. Rancho, Lower Level
4475 S. Eastern
2704 N. Tenaya W ay
4750 W Oakey Blvd
1. Arrive 10 minutes prior to your appointment time for paperwork. If you are late for your appointment, you
may be rescheduled.
3. DO NOT bring children with you to your appointment. We do not have the facilities or the personnel to
provide for their care while your exam is being done.
Listed below are the preparations required for the identified exams. Failure to prepare may result in
rescheduling your appointment.
Abdominal, aorta, gallbladder, bile ducts, liver, and pancreas Ultrasounds
1. Nothing to eat, drink or smoke for 8 hours prior to exam.
2. You may take your medications with a small amount of water on the day of your exam.
Renal (kidney) Bladder Ultrasound **THE BLADDER MUST BE FULL TO HAVE THIS EXAM DONE**
1. Drink 16 oz of water starting 45 mins. Before the exam and finishing ½ hour before the exam.
2. Your bladder will fill during the ½ hour before the exam.
3. DO NOT EMPTY YOUR BLADDER BEFORE THE EXAM.
Pelvic Ultrasound **THE BLADDER MUST BE FULL TO HAVE THIS EXAM DONE**
1. Drink 32 oz of water and finishing 1 hour before the exam.
2. Your bladder will fill during the1 hour before the exam.
OB (OBSTETRICAL) Ultrasound **THE BLADDER MUST BE FULL TO HAVE THIS EXAM DONE**
1. Drink 26 oz of water starting one hour before the exam and finishing 20-30 mins. before the exam.
2. Your bladder will fill during the ½ hour before the exam.
3. Family members are not allowed in the exam room.
Breast, popliteal, testicular, soft tissue, venous, thyroid, transvaginal and carotid Ultrasounds
1. No preparation is needed for these exams.
2. All breast ultrasound patients: please pick up your CD or mammogram films and bring them with you to
your appointment if they were done at a facility other than SMA or you have signed them out.
PD-0799 (04/16)

Frequently Used Forms - Health Plan of Nevada

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