PSF-750 Quick Reference Guide - OptumHealth …

1 OptumHealth Care Solutions Physical Health includes OptumHealth Care Solutions, LLC, ACN Group IPA of New York, Inc., Managed Physical Network, Inc., and ACN Group of California, Inc. R EVISED : 07/01/2015 OptumH eal th Physi cal H eal th. UM D Quick Reference GuideHave your pa tie nt complete:xPa tie nt se ction andxFunctional outcome measure (recommended, but not required)The provider billing for services should complete the remainder of the Patient Summary Form must be received by OptumHealth no later than te n (10) days from the submission start date.

2 The Patient Summary Form can also be submitted online at further process details, please view the tutorial at patient demographic informationIndicat e t he pat ient type for THIS submissionNature of patient s condition for THIS episode(Chiropractic use only)Indicat e ant icipat ed CMT levelPat ient complet es t his sect ion. Please encourage patients to complete as accurat ely as possible, based on current st at usName and credent ials of t he practitioner who is rendering or providing the serv ice*State date for THIS SubmissionEnter referral information (If applicable)Please ensure t hat t he TIN used is t he SAME TIN entered on t he claim, which should correlate to the name of the business ent it y, facility and/or billing providerEnter the ICD diagnosis code( s) *t hat represent t he condit ion( s)

3 That are being addressed during THIS episode of carePlease complet e a Functional Outcome M easure and document t he score in t his sect ionEnt er t he cause of t he current episode of care and/or surgical date and type being addressed during THIS episode of care* F o r C linical Submissio ns w ith start date befo re 10/1/2015 please use IC D-9 co des. F o r C linical Submissio ns w ith start date o n/after 10/1/2015 o nly IC D-10 co des will be accepted.