Provider Forms and Documents
Members enrolled in our HMO and POS products are required to select a Primary Care Physician (PCP) who acts as the coordinator of care for the patient. Members must contact their PCP prior to making appointments with specialty providers. Upon assessment of the patient needs, the PCP may find it appropriate to refer the patient to other participating specialty providers.
The Health Plan contracts with providers in order to obtain quality care at an affordable price. This enables us to contain premium increases to our membership. All services that can be properly performed by Health Plan providers must be referred in-plan. Services, which are not available through this in-plan network require preauthorization via an out-of-plan referral.
In addition to the Provider Manual and that training that accompanies it, The Health Plan Customer Service Represenatives are always available to assist in any way possible by calling 1.800.624.6961/740.695.7901 in St. Clairsville and 1.888.830.4370/740.330.4370 in Massillon. Listed below are links to help you access other helpful resources and documents.
In order to view some of these materials, you will have to have a copy of Adobe Acrobat Reader installed on your computer. If you do not, you can download and install the latest Acrobat Reader software free. Download Adobe Reader.
Standards of Practice & Guidelines
The guidelines below are updated every two years or with changes and mailed to providers. Please call 1.800.624.6961, ext. 7659 or 740.695.7659 if you require another set of guidelines and we will mail them out to you. If you have additional questions about the Disease Management Guidelines, you can call 740.699.6110.
- Guidelines for Preventive Health
- Management of COPD
- Management of Diabetes Mellitus
- Management of Chronic Heart Failure (CHF)
- Substance Abuse
- Management of Depression
- Standards for Patient Records
- Standards for Access to Care and Services
- ER Contact Form
- Emergency Medical Information (EMI)
The Health Plan has devised a form that will provide emergency response personnel and various physicians who may care for the member in event of a hospitalization, with a quick, at-a-glance medical history. Additional information that is important in caring for patients is also included. Emergency response personnel have supported us in the need for this information to be available. We have encouraged our members to complete an EMI form and keep it a location of their choice in their homes.
The Health Plan’s EMI is available to fill out online by clicking the link displayed belowy as a pdf download.
The availability of a free decal identifying that EMI is available in the home can be found at www.vialoflife.
We hope that you will assist your patients if they need help in completing this form. Please feel free to call the Quality Improvement Department at 800.624.6961, Ext. 7659 or 740.695.7659.
- Provider Prenatal Risk Screening Form
- Provider Update Form
Users will need to have the most recent version of Adobe Acrobat or Adobe Reader (7.0 or greater). Users can fill out the following form ONLINE by clicking through the fields or "tabbing". Once the information is properly filled out, users then will click "Submit by Email". (Please note: if a field is required, the form will ask you to fill in the required pieces before sending it or it will not be delivered). Users without the most recent verison of Adobe Acrobat or Reader, can scroll to the bottom of the form and click "Print Form". The form will be printed for the user to manually fill out and return to The Health Plan Provider Relations either by mail or fax.
