[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-286877-105":3,"detail-sidebar-cat-1-en-105":72,"doc-detail-286877-en":118},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":65,"head_meta":67,"extra_data":69,"updated_unix":71},105,"en","umr-pre-determination-fax-cover-sheet","UMR - Pre-Determination Fax Cover Sheet","","This document serves as an official UMR pre-determination request form, designed to facilitate the formal submission of clinical records and medical service requests for benefit evaluation. The template requires detailed patient demographic information, including identifiers, and specific ordering physician or facility credentials. It captures critical billing and clinical data such as ICD-10 codes, specific CPT codes with session frequencies, and relevant service dates. Additionally, the form outlines specialized sections for therapy services like PT, OT, ST, and ABA, ensuring comprehensive documentation for insurance verification. The document explicitly differentiates between pre-determination inquiries and claims processing while emphasizing strict adherence to HIPAA regulations and UMR's proprietary information confidentiality protocols. It is an essential administrative tool for healthcare providers to ensure accurate benefit coverage assessment before delivering services.",{"@graph":14,"@context":64},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/umr-pre-determination-fax-cover-sheet/286877/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/umr-pre-determination-fax-cover-sheet/286877.png","ImageObject",442,249,{"name":42,"@type":43},"Quinn","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-21","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":30},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58],{"name":59,"@type":60,"acceptedAnswer":61},"What information is required for the CPT code section?","Question",{"text":62,"@type":63},"The form requires the 5-digit CPT code, the number of sessions desired, and the specific starting and ending dates for those sessions.","Answer","https://schema.org",{"og:url":32,"og:type":66,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":68,"canonical":32},"index,follow",{"doc_id":70,"site_id":7},286877,1789631647,{"code":4,"msg":73,"data":74},"success",[75,80,85,90,95,100,104,109,114],{"id":76,"doc_module":22,"doc_module_name":25,"category_name":77,"show_sort_weight":78,"slug":79},11,"Presentations",90,"presentations",{"id":81,"doc_module":22,"doc_module_name":25,"category_name":82,"show_sort_weight":83,"slug":84},12,"Resumes",80,"resumes",{"id":86,"doc_module":22,"doc_module_name":25,"category_name":87,"show_sort_weight":88,"slug":89},14,"Invoices",70,"invoices",{"id":91,"doc_module":22,"doc_module_name":25,"category_name":92,"show_sort_weight":93,"slug":94},15,"Posters",60,"posters",{"id":96,"doc_module":22,"doc_module_name":25,"category_name":97,"show_sort_weight":98,"slug":99},16,"Social Media",50,"social-media",{"id":101,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":102,"slug":103},17,40,"forms",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},18,"Letters",30,"letters",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":111,"show_sort_weight":112,"slug":113},21,"Paper Templates",5,"papers-templates",{"id":115,"doc_module":22,"doc_module_name":25,"category_name":116,"show_sort_weight":4,"slug":117},158,"General","general-158",{"code":4,"msg":73,"data":119},{"doc_id":70,"user_id":120,"nickname":42,"user_avatar":121,"doc_module":22,"category_id":101,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":122,"file_id":123,"file_url":124,"file_type":125,"file_size":126,"view_count":30,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":127,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":128,"faqs":129,"seo_title":130,"seo_description":12,"update_tm":71,"read_time":4},962075114765,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","PLEASE COMPLETE FORM AND ATTACH WITH CLINICAL RECORDS  \nFax 877-442-1102  \nPlease contact the benefit department via the phone number on the insureds medical ID card for benefits on the procedure you are inquiring on. A predetermination review or when reviews are not needed does not guarantee benefits. Benefit department would advise level of coverage or if care is non-covered within the plan the patient has.  \nTo: PRE-DETERMINATION DEPT  \nFrom:    \nPatient name:   Patient’s DOB:   ID \\#   Group\\#   \nOrdering Physician:  Credentials:   Address:   City:  State: Zip:  Phone \\#:    \nFAX:    \nNPIN   \nFacility:    \nFacility Tax Id:   \nFacility address:    \nFacility phone\\#:    \nDATE OF SERVICE:    \nICD-10:    \nCost for genetic testing, DME equip cost, or cost of drug   CPT CODE (5 digit code): enter number of sessions desired for each CPT requested: CPT: ( ) x ( ) sessions starting date ( ) to ending date ( )  \nCPT: ( ) x ( ) sessions starting date ( ) to ending date ( )  \nCPT: ( ) x ( ) sessions starting date ( ) to ending date ( )  \nFOR PT/OT/ST/ABA  \nHow many visits has patient used?    \nPrior case \\# on file:  \n*** PLEASE NOTE THIS IS ONLY FOR PRE DETERMINATION OF SERVICES. CLAIMS NEED TO BE FAXED TO 877-291-3247. ***  \nInformation included in this document is considered to be UMR’s confidential and/or proprietary business information. Consequently, this information may be used only by the person or entity to which it is addressed by UMR for a legitimate purpose. Such recipient shall be liable for using and protecting UMR’s proprietary business information from further disclosure or misuse. The report you have received may also contain protected health information (PHI) and must be handled according to applicable law, including but not limited to  \nHIPAA. Individuals who misuse information may be subject to both civil and criminal penalties","cbCaifIQ0LglhM24","https://ap.wps.com/l/cbCaifIQ0LglhM24","pdf",106184,"English","# Patient and Provider Information\n## Service and Billing Details\n## Regulatory and Confidentiality Notices","[{\"question\":\"What information is required for the CPT code section?\",\"answer\":\"The form requires the 5-digit CPT code, the number of sessions desired, and the specific starting and ending dates for those sessions.\"}]","UMR - Pre-Determination Fax Cover Sheet | PDF"]