Download External Beam Intraoperative Radiation Therapy

REVIEW REQUEST FOR
External Beam Intraoperative Radiation Therapy
Provider Data Collection Tool Based on Coverage Guideline RAD.00017
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/13/2015
Provider Tool Effective Date: 01/14/2014
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s 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:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
Please check all that apply to the individual:
Request is for external beam intraoperative radiation therapy (IORT)
IORT is being used as the sole source of boost therapy at the time of surgical excision for: (Check all that apply)
Colorectal cancer
Pancreatic cancer
Pelvic malignancies (for example, cervical or uterine)
Soft tissue sarcomas
Breast cancer
Other (Please list)
Tumor cannot be completely removed
Tumor has a high risk of recurring in surrounding tissues
Other (Please list)
Page 1 of 2
REVIEW REQUEST FOR
External Beam Intraoperative Radiation Therapy
Provider Data Collection Tool Based on Coverage Guideline RAD.00017
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/13/2015
Provider Tool Effective Date: 01/14/2014
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 the health plan or its
designees 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
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
Page 2 of 2