University Community Care Plan Provider Manual

• EXHIBIT 1: Request For Continuity of Care
• EXHIBIT 2: Provider Request for Member Transfer
• EXHIBIT 3: Community First Authorization List
• EXHIBIT 4: University Community Care Plan Member ID Card
• EXHIBIT 5: Texas Standard Prior Authorization Request Form for Health Care Services
• EXHIBIT 6: Medical Record Review Tool
• EXHIBIT 7: American Academy of Pediatrics Recommendations For Preventative Pediatric Health Care
• EXHIBIT 8: CDC Adult Preventative Care Recommendations
• EXHIBIT 9: Consent to Use Physician Assistant/Nurse Practitioner
• EXHIBIT 10: Member Education Request Form
• EXHIBIT 11: CMS-1500 Form and Instruction Table
• EXHIBIT 12: UB 04 Claim Form and Instructions
• EXHIBIT 13: Explanation of Payment (EOP)
• EXHIBIT 14: Suspicious Activity Report (Member)
• EXHIBIT 15: Suspicious Activity Report (Provider)
• EXHIBIT 16: Claims Department Appeal Submission Form
• EXHIBIT 17: Provider Complaint Form
• University Community Care Plan Provider Manual