Forms

Hospital Contact Form
Acentra Health keeps the hospital community informed of Healthcare and Family Services (HFS) program changes and sends review notices and updates through communication sent by fax, mail or phone. The following four contacts at your facility play a vital role in receiving and disseminating this information:

eQHealth Liaison
The Liaison is assigned by a member of hospital administration. Their role is to serve as the primary hospital contact regarding utilization program information. It is important to have the appropriate liaison to ensure the information is received by this hospital designee and distributed in a timely manner.

Quality Contact
This contact is identified by hospital administration. Their role is to be the primary quality contact between Acentra and the hospital for all issues relating to quality matters. All quality communication is sent to this contact.

Web Administrator
To access our Web-based review system and provider-specific reports, each hospital must have a Web account and designate a Web administrator for their facility. The Web administrator defines the access rights for all hospital Web users and is responsible for creating login information and maintaining user profiles.

Retro Chart Contact
This hospital-assigned contact will receive an email reminder whenever cases are selected by HFS for retrospective pre- or post-payment medical record review. The email will remind you to have someone logon to eQSuite to get the list of cases and upload medical record sections online.

To add, update or change these contacts, please fill out the Hospital Contact Form and fax it back to us with the updated information.

Would you like to submit a request for reconsideration of a medical necessity denial?
For a copy of the Reconsideration Request form Click here.