Home
About us
Contact Us
Nurse Triage / Access24
Managed Care Services
PPO NETWORK / BILL REVIEW
Comprehensive Pharmacy Management
Case Management
TELEPHONIC CASE MANAGEMENT
FIELD CASE MANAGEMENT
VOCATIONAL SERVICES
DISABILITY CASE MANAGEMENT
Utilization Management
WORKERS COMPENSATION
SUBMIT A UR REFERRAL
GROUP HEALTH SERVICES
Medical Review Services
LIFE CARE PLANNING
MEDICAL NEEDS ASSESSMENT
MEDICARE COMPLIANCE SERVICES
POST AWARD REVIEW & MANAGEMENT
LIABILITY CLAIMS MEDICAL REVIEW
LEGAL MEDICAL REVIEW
SUBMIT A UR REFERRAL
Home
>
SUBMIT A UR REFERRAL
BHN Request for Utilization / Medical Review Services
Step 1 of 4
Claimant
Claimant Name
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Social Security #
Date of Birth
Type the code from the image