Free 22032.FH11 - Indiana


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Date: April 20, 2007
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State: Indiana
Category: Government
Author: sbundy
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http://www.state.in.us/icpr/webfile/formsdiv/22032.pdf

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AUTHORIZATION FOR EXAMINATION TO DETERMINE DISABILITY FOR MEDICAL ASSISTANCE
State Form 22032 (R13 / 4-07) / OMPP 0251

Case name MRT ID number 850

Dear: You are hereby authorized to examine the above individual who has applied for medical assistance based on disability. Further additional authorization is not required. If you completed a report on an examination that was given in the past three (3) months, a reexamination is not necessary and a report will be sufficient. Diagnostic procedures, such as laboratory tests, x-rays, and special testing may be performed only if listed in the most recent Bulletin BT200620 (10/27/06) and will serve to confirm the diagnosis or severity of the impairment(s). All testing must be billed utilizing the approved CPT code, with reimbursement based according to the Medicaid fee-for-service schedule applicable on the date of service. This letter is not an authorization for treatment. Please enter your findings on the attached OMPP form 0251A - Determination of Disability, Medical Information. Return the original and one (1) additional copy to this office. We will keep the form and will forward one (1) copy to the Indiana Medicaid Medical Review Team (MMRT). Any possible third party liability must be billed before a claim may be submitted to Medicaid (EDS). For reimbursement determination, your claim can be filed utilizing the CMS-1500 or electronically on Web InterChange at http://www.indianamedicaid.com/ihcp/ProviderServices/ProviderSearch.asp. For more information, please refer to Bulletin BT200620 (10/27/06) located on the IHCP Web site. Providers who have specific questions about claims may contact the EDS Customer Assistance Unit at (317) 655-3240 in the Indianapolis area, or toll free at 1-800-577-1278. Providers should submit paper CMS-1500 claim forms to the following address: EDS CMS 1500 Claims PO Box 7269 Indianapolis, IN 46207-7269 As this office is under federal mandate to process medical assistance applications promptly, your cooperation and quick response is vital and appreciated. If you have further questions about eligibility, feel free to contact this office.

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