Provider Manual Exhibits

• Exhibit 2: Pre-Service Review Request Fax Form
• Exhibit 5: Concurrent Review Request Fax Form
• Exhibit 7: Psychiatric Admit Notification Information (For Individuals Under the Age of 21)
• Exhibit 8: Psychiatric Worksheet for Pre-Service Review (Clients 21 Years or Older)
• Exhibit 9: Psychiatric Review Worksheet for Concurrent Review (All Ages)
• Exhibit 10: Physical Rehabilitation Review Worksheet for Pre-service Review
• Exhibit 12: Retrospective Review Request Form
• Exhibit 13: Administratively Necessary Days (ANDs) Intake Form
• Exhibit 19: Notification of Birth: Anticipated Stays Greater Than 72 Hours
• Exhibit 20: iEXCHANGE^® Sample of IMD Questionnaire

Pre-Authorization List - July 2010
Also known as Appendix A in the Provider Manual.

Checklist for Procedure Authorization Reviews

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