REVIEW REQUEST FOR

Manipulation Under Anesthesia of the Spine and

Joints other than the Knee

Provider Data Collection Tool Based on Medical Policies 8.01.40;MED.00079

Policy Last Review Date: 10/2010; 05/13/2010 / Policy Effective Date: 10/2010; 07/07/2010 / Provider Tool Effective Date: 03/15/2011
Member Name: / Date of Birth:
Insurance Identification Number: / Member Phone Number:
Ordering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Rendering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Facility Name: / Facility ID Number:
Facility Address:
Date/Date Range of Service: / Place of Service: Home Inpatient
Outpatient Other:
Service Requested (CPT if known):
Diagnosis (ICD-9) if known):

Please check all that apply to the individual:

Request is for manipulation under anesthesia (MUA)of the shoulder for treatment of adhesive capsulitis (frozen shoulder)

Request is for spinal manipulation under anesthesia (SMUA). (Check any that apply)

Treatment of vertebral fracture

Treatment of complete dislocation

Treatment of acute traumatic incomplete dislocation (subluxation)

Other (please list): ______

Request is for manipulation under anesthesia of joint other than the knee, shoulder or spine

Other (please list): ______

Other (please list): ______

This request is being submitted:

Pre-Claim

Post–Claim. If checked, please attach the claim or indicate the claim number

I attest the information provided is true and accurate to the best of my knowledge. I understand that Anthem may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.

______

Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)* Date

*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted

Page 1 of 2

REVIEW REQUEST FOR

Manipulation Under Anesthesia of the Spine and

Joints other than the Knee

Provider Data Collection Tool Based on Medical Policies 8.01.40;MED.00079

Policy Last Review Date: 10/2010; 05/13/2010 / Policy Effective Date: 10/2010; 07/07/2010 / Provider Tool Effective Date: 03/15/2011

Page 1 of 2