MCO References

Managed Care Reference Form

(To be completed by case manager, provider relations director, EAP or other Managed Care Organization official)

 

________________________________________________________________________________________________________________________________________________

Applicant Name                                                       Degree                                  License Type                            License Number                                     State

 

 

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Reference Name                                                     Degree /Title                                                                                   Company

Note to the managed care organization reference:The above named individual has made application for Diplomate status in the Academy of Managed Care Providers. One of the criterion used to assess this candidate’s eligibility for election as a Diplomate is his/her successful attainment of pre-determined thresholds on this form. Your thoughtful consideration of your responses is greatly appreciated. Please circle the number under each statement that best describes this applicant’s abilities as known by you. A score of “1” is a “poor” rating and a score of “10” is an “excellent” rating. Your responses will be kept strictly confidential. Please return this form directly to the Academy at the address or FAX number printed below. Thank you for your assistance.

Knowledge and understanding of managed care principles and procedures

1_________2_________3_________4_________5_________6_________7_________8__________9_________10

Skill in the development of clinically effective and appropriate treatment goals

1_________2_________3_________4_________5_________6_________7_________8__________9_________10

Ability to resolve conflicts or differences of opinion with MCO staff in a professional manner

1_________2_________3_________4_________5_________6_________7_________8__________9_________10

Ability to effectively formulate and communicate the treatment plan, treatment modalities and discharge plans

1_________2_________3_________4_________5_________6_________7_________8__________9_________10

Completes episodes of clinical care within a reasonable amount of time

1_________2_________3_________4_________5_________6_________7_________8__________9_________10

Files reports and returns telephone calls in a timely manner

1_________2_________3_________4_________5_________6_________7_________8__________9_________10

 

Interacts with MCO staff in a cooperative, collegial manner

1_________2_________3_________4_________5_________6_________7_________8__________9_________10

Awareness and utilization of collateral resources in the community

1_________2_________3_________4_________5_________6_________7_________8__________9_________10

Ability to provide quality clinical care within managed care guidelines

1_________2_________3_________4_________5_________6_________7_________8__________9_________10

 

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  Signature                                                                                                                                                          Date

Please return this form directly to:

ACADEMY OF MANAGED CARE PROVIDERS

1945 Palo Verde Avenue, Suite 202

Long Beach, CA 90815-3445

(562) 682-3559 FAX (562) 799-3355