Commercial Medical -Surgical Clinical Data Submission Tools
PW_B138549
A Pre-certification or Predetermination Tool is used by the provider to submit clinical information for an authorization request (precert or predetermination). If a provider uses this tool, chart records and letters of medical necessity will not be needed unless the tool is selected for auditing.
The Clinical Data Submission Tools on this site may be used to submit clinical information for either a pre-service review (pre-certification or pre-determination) or Post Service review, including pre or post claim submission.
The patient's demographic information should be completed in the first section of the tool.
The patient's clinical information should be completed in the second section of the tool by checking the series of boxes all that applies to the patient's medical condition.
After completion of the Clinical Data Submission Tools-, the information should be submitted to the Utilization Management address or fax number referenced in this contact list. If you would like to submit the tool via e-mail, please contact the Utilization Management Department to obtain the appropriate address to submit the tool. If you are not set up for secure E-Review and would like to be, please contact the Utilization Management Department.
The information, when filled out completely, should provide Utilization Management the necessary clinical information, including condition and history, to determine if the case meets the medical necessity criteria.
In some select situations, you may be asked to submit medical records (such as random auditing), or additional information such as photographs or visual fields, as an example.
Please make sure that physician or physician representative signs and checks the attestation at the bottom of the Clinical Data Submission Tool before submitting for review.
