Insurance Name

 

Hospital Service

Referral Form Required

 

Pre-Certification

Phone Reference

 

Initiating Provider

 

Americhoice of Pennsylvania

Americhoice Medicare

Inpatient

Acute Care Elective

Non-Elective

Extended Acute

 

Yes

No

No

 

Yes

Yes

Yes

 

Admitting

Physician

Billing Address:

Skilled Nursing Facility

No

Yes

Admitting Physician

Information Network Corp

Outpatient

 

 

 

PO Box 7630

Emergency Room Visits

No

No

 

Phoenix, AZ 85011-7630

Same Day Surgery

Yes

Yes

PCP/Specialist

 

Diagnostic Radiology

Yes

No

PCP

Eligibility 800-345-3627

CT Scan

Yes

No

PCP

 

Stress Test

Yes
No

PCP

Pre-Certification 215-473-0938

Nuclear Stress Test

Yes

No

PCP

 

Echo

Yes

No

PCP

Provider Services 800-345-3627

Ultrasound

Yes

No

PCP

 

Chemotherapy

Yes

Yes

PCP

 

Laboratory

 

 

 

 

Capitated with Quest

Yes Quest Lab Form

No

 

 

STAT testing at Hospital

Yes Write stat on form

No

 

 

Pre-Admission Testing

Yes See note #1

 

PCP/Specialist

Referral is good for 30 days

Cardiology Department

Yes

No

PCP

Number of visits on referral

Physical Therapy

Yes

No

PCP

 

Speech Therapy

Yes

No

PCP

Contact Person:

Occupational Therapy

Yes

No

PCP

Angel Pagan

Pulmonary/Respiratory

Yes

No

PCP

215-832-4643

Gastroenterology

Yes

No

PCP

 

Infusion

Yes

No

PCP

 

Gilda C. Chinnici, CHAM Permission Required Riv. 8-99