RECOMMENDER REQUIRED PRE-AUTH GROUP A PRE-AUTH GROUP B

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1 DESCRIPTI (OSI) ADDICTIS ASSESSMENT Aug-15 N (OSI) ADDICTIS TREATMENT Aug-15 N (OSI) MENTAL HEALTH NURSE ASSESSMENT Aug-15 N (OSI) MENTAL HEALTH NURSE TREAMENT Aug-15 N (OSI) MENTAL HEALTH NURSE TREATMENT (INDIVIDUAL) Aug-15 YES Y (OSI) PHARMACOTHERAPY(PSYCHIATRIST) TREATMENT Aug-15 YES Y (OSI) PHYSIOTHERAPY TREATMENT (GROUP) Aug-15 $140.00/HR N (OSI) PHYSIOTHERAPY TREATMENT (INDIVIDUAL) Aug-15 $111.00/HR N (OSI) PSYCHIATRIC NURSING INTAKE Aug-15 YES Y (OSI) PSYCHIATRIST ASSESMENT (INDIVIDUAL) Aug-15 YES Y

2 DESCRIPTI (OSI) PSYCHIATRIST TREATMENT (GROUP) Aug-15 N (OSI) PSYCHIATRIST TREATMENT (INDIVIDUAL) Aug-15 N (OSI) PSYCHO-EDUCATI PROGRAM ASSESSMENT (GROUP) Aug-15 N (OSI) PSYCHOLOGIST ASSESMENT(INDIVIDUAL) Aug-15 YES Y (OSI) PSYCHOTHERAPIST TREATMENT (GROUP) Aug-15 YES Y (OSI) PSYCHOTHERAPIST TREATMENT (INDIVIDUAL) Aug-15 YES Y (OSI) SOCIAL WORKER (FAMILY) Aug-15 YES Y (OSI) SOCIAL WORKER (GROUP) Aug-15 N (OSI) SOCIAL WORKER ASSESSMENT (INDIVIDUAL) Aug-15 N (OSI) SOCIAL WORKER TREATMENT (INDIVIDUAL) Aug-15 YES Y

3 DESCRIPTI ACUPUNCTURIST - VISIT Aug-15 MD, NP, PT, PA YES 10/CY $80.00/HR Y THIS SERV. MUST INCLUDE AN ASSESSMENT AND A DISCHARGE SUMMARY ADDICTI COUNSELLING (OUTPATIENT) Aug-15 MD YES 10/12 CM Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR CFHS REQUESTED OT S Aug-15 YES $ PER HOUR Y FOR AMENDMENTS AND ADDITIAL JUSTIFICATI CHIROPODIST - VISIT Aug-15 MD, NP, PT, PA YES 5/CY $60.00 Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR CHIROPRACTIC ASSESSMENT Aug-15 MD, NP, PT, PA YES $ Y THE COST OF THIS SERVICE MUST INCLUDE THE CHIROPRACTOR - VISIT Aug-15 MD, NP, PT, PA YES 10/CY $70.00 Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR FUNCTIAL CAPACITY EVALUATI Aug-15 MD, PH YES Y THE COST OF THESE ITEMS MUST INCLUDE THE HEALTH PROMOTI - WEIGHT CTROL AND REDUCTI Jan-00 YES N HOME CARE - DIETICIAN Aug-15 MD, NP, PA YES Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR HOME CARE - MD FAMILY/SPECIALIST VISIT Aug-15 MD YES Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR

4 DESCRIPTI HOME CARE - NEEDS ASSESSMENT BY OT Aug-15 MD, NP, OT, PA YES Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR HOME CARE - NURSE PRACTIER VISIT Aug-15 MD, NP, PA YES Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR HOME CARE - OCCUPATIAL THERAPIST VISIT Aug-15 MD, NP, PT, OT, PA YES 10/12 CM Y THIS SERVICE MUST INCLUDE S AFTER EVERY VISIT AND DISCHARGE HOME CARE - OCCUPATIAL THERAPY ASSESSMENT Aug-15 MD, NP, PA YES Y THE COST OF THESE ITEMS MUST INCLUDE THE HOME CARE - PHARMACIST VISIT Aug-15 MD, NP, PA YES Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR HOME CARE - PHYSIOTHERAPIST VISIT Aug-15 MD, NP, PT YES Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR HOME CARE - PSYCHOLOGY Aug-15 MD YES 10/12 CM Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR HOME CARE - RESPIRATORY MEDICINE Aug-15 MD YES Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR HOME CARE - SOCIAL WORKER VISIT Aug-15 MD, NP, PA 10/12 CM N THIS SERVICE MUST INCLUDE S AFTER EVERY VISIT AND DISCHARGE HOME CARE - SPEECH LANGUAGE PATHOLOGIST - ASSESSMENT Aug-15 MD, NP, PA YES Y THE COST OF THESE ITEMS MUST INCLUDE THE

5 DESCRIPTI HOME CARE - SPEECH LANGUAGE PATHOLOGIST - VISIT Aug-15 MD, NP, PA YES 10/12 CM Y THIS SERVICE MUST INCLUDE S AFTER EVERY VISIT AND DISCHARGE MASSAGE THERAPY - VISIT Aug-15 MD YES 15/CY $91.00 Y APPROVAL BY D MED POL.MUST INCLUDE ASSESS&DISCHARGE S MISSED APPOINTMENTS May-00 YES Y NUTRITIIST VISIT Aug-15 MD, NP, PA N PROVIDER NOTE: VERIFY PROVIDER PKG FOR OCCUPATIAL THERAPIST - HOME MODIFICATIS/ADAPTATI ASSESSMENT Aug-15 MD, PH YES 1/LT Y THE COST OF THESE ITEMS MUST INCLUDE THE OCCUPATIAL THERAPIST - VEHICLE MODIFICATIS/ADAPTATI ASSESSMENT Aug-15 MD, PH YES Y THE COST OF THESE ITEMS MUST INCLUDE THE OSTEOPATH - VISIT Aug-15 MD, NP, PT, PA YES 10/CY $80.00/HR Y THIS SERV. MUST INCLUDE AN ASSESSMENT AND A DISCHARGE SUMMARY OTHER RELATED HEALTH CARE SERVICE Aug-15 MD, NP, PA YES Y PHYSIOTHERAPIST - VISIT Aug-15 MD, NP, PT, PA YES 10/CY $75.00/HR Y THIS SERVICE MUST INCLUDE S EVERY 10 VISITS AND DISCHARGE PHYSIOTHERAPY - ASSESSMENT Aug-15 MD, NP, PT, PA YES $ Y THE COST OF THIS SERVICE MUST INCLUDE THE

6 DESCRIPTI PODIATRIST - VISIT Aug-15 MD, NP, PT, PA YES 5/CY $70.00 Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR PSYCHOLOGIST - INDIVIDUAL VISIT Aug-15 MD YES 10/12 CM Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR PSYCHOLOGIST - MARITAL OR FAMILY VISIT Aug-15 MD YES 10/12 CM Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR PSYCHOLOGIST - OTHER Aug-15 MD YES 10/12 CM Y PSYCHOLOGIST Aug-15 N SOCIAL WORK - INDIVIDUAL VISIT Aug-15 MD YES 10/12 CM Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR SOCIAL WORK - MARITAL OR FAMILY VISIT Aug-15 MD YES 10/12 CM Y PROVIDER NOTE: VERIFY PROVIDER PKG FOR SOCIAL WORKER Jul-07 N SPEECH LANGUAGE PATHOLOGIST - ASSESSMENT Aug-15 MD, NP, PA YES Y THE COST OF THESE ITEMS MUST INCLUDE THE SPEECH LANGUAGE PATHOLOGIST - VISIT Aug-15 MD, NP, PA YES Y MUST INCLUDE ASSESSMENT AND PROGRESS S AFTER EVERY VISIT

7 DESCRIPTI TAXES - GST/HST (GST/HST REGISTRATI NUMBER ) 0TPS 04-Jan-00 N TAXES - GST/HST (GST/HST REGISTRATI NUMBER ) 0GST 01-Jun-10 N TELEMENTAL HEALTH Aug-15 MD 10/12 CM N

8 CHIROPRACTOR CLINICAL AUDIOLOGIST CHIROPODIST CANADIAN NATIAL INSTITUTE FOR THE BLIND (CNIB) DERMATOLOGIST DIETITIAN ENDOCRINOLOGIST NEUROLOGIST EAR, NOSE AND THROAT SPECIALIST/OTORHINOLARYNGOLOGIST ENTEROSTOMAL THERAPIST GENERAL SURGE HANDICAPPED DRIVING CENTER HEARING INSTRUMENT PRACTITIER INTERNAL MEDICINE SPECIALIST MEDICAL ASSISTANT METABOLIC CENTRE MEDICAL DOCTOR (GENERAL PRACTITIER / MEDICAL SPECIALIST) NEUROLOGIST NURSE PRACTITIER NEUROSURGE OPHTHALMOLOGIST OPHTHALMIC TECHNICIAN ORTHOTIST OPTOMETRIST ORTHOPEDIC SURGE OCCUPATIAL THERAPIST PODIATRIST PSYCHIATRIST PEDORTHIST PHYSIATRIST PHYSICAL MEDICINE PROSTHETIST PLASTIC SURGE PHYSIOTHERAPIST PSYCHOLOGIST RHEUMATOLOGIST REGISTERED NURSE RESPIRATORY MEDICINE SPECIALIST RESPIRATORY TECHNOLOGIST SPEECH LANGUAGE PATHOLOGIST SPECIALIST IN REHABILITATI MEDICINE SOCIAL WORKER TRAUMA COUNSELLING UROLOGIST C CA CH CI D DI EC EN ES ET GS HD HP IM MA MC MD N NP NS O OC OH OP OS OT P PC PD PH PM PR PS PT PY RH RN RP RT SL SR SW TC U

9 VASCULAR SURGE WATER INTERPRETATI ANALYSIS VS WA

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