Use Emerge to view or confirm receipt of CCF/PMH or MR after it is received. These are usually associated with claims coded "08". You can also use the Claims module of Emerge, search for all claims, and then search for claims with a note which includes (MR) or (PMH). See claim number 2021012200371.00 for member ID 1101431.
When the insured request to have the CCF/PMH letter resent to them, there is a way for us to print them ourselves and send them. Please see below for instructions.
You would first have to find out which examiner sent the initial CCF/PMH form, for example Lisa Kegley. The examiner name will be in Emerge. Please click on the details button and read the notes.
1. You would need to go into the H drive when the carrier is Hartford
2. Chose JMS Correspondence
3. If the policy is Hartford. Locate the oldest date we sent CCF/PMH. Open that folder and locate your patient's name. Create a new email, and attach all of your patient's documents and email it to them.
All emails must be placed in Imagenow. Leave detailed notes.
**NOTE: if the insured has a common last name such as Jones, or Smith. Type in the first and last name and locate your insured.
If the insured has a unique last name you most likely won't need the first.
4. You would need to choose the insured person name, claim form will be listed next to the name. it would look something like this
LK Sarah Stewart claim form
5. Once you click on the information, it will bring up the PMH letter that was sent initially. Please be sure to print all of the letter we sent. There may be multiple, please look for all of them.
The member can give us permission to release protected health information to other parties by completing an
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AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION | ||||
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You may authorize us in writing to share protected information with a third party such as a family member, friend, employer, lawyer, broker, etc. This authorization will be effective once it is entered into our system. | ||||
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Member Information |
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Name of Member ___________________________________________________ |
Member ID# _____________________ |
Member Date of Birth _____________________ |
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Member Address (Street, City, State & Zip Code) __________________________________________________________________________________________________ | ||||
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At my request, I authorize release of protected information to: |
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First Name: ___________________________________ |
Last Name: ___________________________________ |
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Relationship to Member: ________________________________________________________________________ | ||||
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2. |
First Name: ___________________________________ |
Last Name: ___________________________________ |
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Relationship to Member: ________________________________________________________________________ | ||||
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3. |
First Name: ___________________________________ |
Last Name: ___________________________________ |
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Relationship to Member: ________________________________________________________________________ | ||||
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3. |
I authorize the following disclosure to the person/organization listed above. Check all that apply: |
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All of my information |
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Claims and EOBs |
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Enrollment and Benefits information |
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Premium Payment |
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Any document related to an appeal |
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Mental Health/Substance Abuse |
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Other: |
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To further limit the information being shared, please be specific as possible when selecting the options below: |
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All services for a specific date range (provide date range): From:__________________ To: __________________ |
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All services from a specific health care provider (list provider’s name): ____________________________________________________________________________________________ ____________________________________________________________________________________________ |
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Other: |
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Expiration |
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I would like this authorization to expire on this date: __________________________________________________ |
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I would like this authorization to remain in effect until I revoke it in writing. |
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Right to Revoke (Cancel) |
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I understand that I may revoke this authorization at any time by giving written notice to Selman & Company, One Integrity Parkway Cleveland, OH 44143 | ||||
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6. |
Signature |
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I hereby authorize the use and/or disclosure of my identifiable protected information as described above. I understand that this designation is voluntary and being made at my request; the released information may no longer be protected by federal privacy laws and may be re-disclosed by the individual or organization authorized to receive the information; and this authorization will not be used for medical underwriting. As such, my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on my signing this authorization. I have had full opportunity to read and consider the contents of this authorization, and I confirm that the contents are consistent with my direction to Selman & Company. I understand by signing this form, I am giving my authorization to Selman & Company to use and/or disclose the protected information described above to the persons and/or organizations named in this form. Signature: _____________________________________________________________ Date: _____________________ Print Name: ____________________________________________________________ If the person signing this authorization is not the member, please provide your full name and relationship to the member. Proper documentation of your authority to sign this form on behalf of the member must be on file before this authorization can be processed. Print Your Full Name: ________________________________________________________________________________ | |||||||||||
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Personal Representative |
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Power of Attorney |
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Legal Guardian |
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Other _______________ |
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Please mail or fax this authorization to:
Selman & Company One Integrity Parkway Cleveland, OH 44143 Fax: 1-800-311-3124 |
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Please keep a copy of this authorization. We will provide you with a signed copy upon request. Any mental health or substance abuse information, which has been disclosed from medical or other health care records may be protected by federal and/or state law. If the records are protected, Federal Regulation (42 CFR Part 2) prohibits the recipient of the information from making any further disclosure of this information unless such disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. | |||||||||||