Report Request
Use to request Ad Hoc or Crystal Reports
Requester Name
*
E-mail
*
Requested Due Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
If requesting single county report, select county
Berks
Blair
Adams
York
Lackwawanna
Luzerne
Susquehanna
Wyomining
Clinton
Lycoming
If requesting joinder report, select joinder
York-Adams
Lycoming-Clinton
Lackawanna/Susquehanna
Luzerne/Wyoming
Lackawanna, Luzerne, Susquehanna, Wyoming combined
Data Type
*
Authorizations
Claims
Other
Basis for Measurement
*
Service Dates
Payment Dates
Authorization Dates
Describe the time period to be measured. For example Fiscal year 13/14, or Calendar year 2014, or enter a specific date range.
Level of Care
*
BHRS
RTF
Inpatient MH
D&A Non-Hospital Detox
D&A Non-Hospital Rehab
D&A Hospital Detox
D&A Hospital Rehab
D&A Halfway House
Case Management
Ancillary
Outpatient MH
Partial Hosp
Outpatient D&A
Methadone
Psych Rehab
Peer Specialist
Crisis
Family Based
School Based BH
Other
List procedure codes and modifiers or other service specific information
What information would you like to see on the report?
*
Member level detail
Aggregate/summary
Other
If member level detail is requested, please list all fields you would like to see appear on the report (e.g., member name, dob, etc.)
For aggregate report select summary fields.
Distinct member counts
Payment sums
Other
Please list all grouping categories and sort order.
Age Parameters (if not specified, all ages will be included)
Provider Names and/or IDs (if not specified, all providers will be included)
Diagnoses to Include/Exclude (if not specified, all diagnoses will be included)
What question(s) are you trying to answer with this report?
*
Please provide any additional information needed to complete this report
Report type
Ad hoc
Crystal Report (select only if the report will be run routinely)
Both
Submit
Clear Form
Should be Empty: