Peer-to-Peer Scheduling Request Form

Magnolia Health offers an electronic, fillable form for providers to request a Physician-to-Physician Peer-to-Peer discussion regarding medical necessity determinations. This process allows the requesting provider to speak directly with a Magnolia Health Medical Director to review a denied service or treatment.

PLAN

PROVIDER INFORMATION

National Provider Identification (NPI): * (10 digits)

Provider Last Name: * Enter Last Name

Provider First Name: * Enter First Name

Treating Physician’s Title: * MD, DO, NP, PA

Treating Physician’s Contact Number *

Scheduler’s Name and Contact Number: * 10 Digits including area code

MEMBER INFORMATION

Member ID: *

Date of Birth: *

Member Last Name *

Member First Name: *

Authorization Number: *

SCHEDULING DETAILS

Option 1

Date *

Time

Option 2

Date *

Time

Option 3

Date *

Time