Utilization Review Referrals

Utilization Review Referrals2020-12-16T16:44:55-05:00

Date of Referral*
MM slash DD slash YYYY
Referred By*
Company*
Address
Street Address City State ZIP Code
Phone*
Fax (no dashes please)*
Email*
Insured
Claimant
Date of Birth
Date of Loss
Claim Number
Injury
Return bills to (if different from above)
Coverage
Type of Coverage
State of Coverage
Reconsideration
- For Reconsideration please submit all documentation to ManageAbility. We will address with the provider.
Professional Review
Type of Review
Provider name
Provider phone
Special requests
Bill Repricing by Line
Fee schedule
- Fee schedule (for WC fee schedule states) or Reasonable and Customary (database)
Special Repricing Requests
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