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Outpatient Treatment Review Form

PW_AD088366
Entering your OTR on-line will just take a few minutes. Your electronic submission allows you to provide clear clinical information and reduces processing errors. No login is necessary in this working prototype and the data will be sent to Anthem’s clinical staff automatically. Follow these instructions for best results.   
Gather information needed:  
Member Information and ID Card number.
Diagnosis information (Axes I thru V).
Enter the OTR Information starting at the link below.
Submit the OTR after a careful review of accuracy.
Print or Save your OTR for future reference.
File…Print…Properties… and choose landscape prior to printing.
 
Because of HIPAA regulations, we do not currently allow a retrieval of a previously submitted OTR form. So printing a hardcopy or saving the OTR data to your local computer is important. FOR BEST RESULTS – change you printer setting to Landscape. Do set this choose in your browser the following:   
  
File…Print…Properties… (and choose landscape prior to printing).   
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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use