Silverback Care Management

Silverback Care Management

Phone: 855-359-9999

Fax: 888-965-1964

 Pre-Certification

 Referral/Notification

Health Plan/Payor:

 United Healthcare

 Care N’ Care PPO

 Care N’ Care HMO

 Humana Gold Plus

Submitted by:

 PCP Office

 Specialist Office

Today’s Date:

/

/

(select one)

Patient’s Name:

DOB

/

/

Member ID:

Patient PCP:

NPI:

Contact Name:

Contact Phone:

FAX:

Proposed Date of Service:

/

/

Treating Provider:

NPI:

Other Provider Name:

NPI:

(i.e. Facility, DME)

Phone:

FAX:

 Outpatient

 Office

 Inpatient

 DME

 Ambulatory Surgery Center

Health-e-Care:  Clinic Visit (All)

 Clinical Pharmacist  Social Services

 Advance Care Planning (MOST)

ICD-10 CM Diagnosis Description

ICD-10 CM Code

Procedure: CPT/HCPCS Exact Description

CPT/HCPC Code

Describe any special circumstances which should be considered when authorizing services:

Clinical Information: (You may attach additional clinical)

This request will be treated as per the standard organization determination timeframes. If the request needs to be treated as

expedited, clinical justification must be provided that applying the standard time for making a determination could seriously jeopardize

the life or health of the member or the member’s ability to regain maximum function:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Authorization does not guarantee or confirm benefits will be paid. Payment of claims is subject to eligibility, contractual limitation, provisions and

exclusions.

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3/7/2016