From Wv-16-06-01 - Aetna Prior Authorization Form

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Aetna Better Health® of West Virginia
500 Virginia Street East, Suite 400
Charleston, WV 25301
Prior Authorization Form
Fax to: 1-866-366-7008 Telephone: 1-844-835-4930
A determination will be communicated to the requesting provider.
•
Incomplete requests will delay the prior authorization process.
•
Please include pertinent chart notes to expedite this request.
TYPE OF REQUEST
URGENT
INPATIENT
(When a 7 calendar day non-urgent prior authorization could seriously jeopardize; the
life or health of a member, the member’s ability to attain, maintain, or regain maximum function,
OUTPATIENT
or that a delay in treatment would subject the member to sever pain that could not be adequately
managed without the are/service requested.)
HOME HEALTH CARE
NON-URGENT
(for routine services – response within 7 calendar days)
PATIENT INFORMATION
Patient Name:
Last
First
MI
Date of Birth:
/
/
I.D.#:
Gender:
EPSDT special service request?
M
F
Other Insurance?
Name of Carrier
Job Related?
MVA?
Is the member currently pregnant
YES
NO
YES
NO
YES
NO
YES
NO
FROM- REQUESTING PROVIDER
Requesting Provider (Please Print):
Tax ID#:
Contact Person in Requesting Provider’s
Telephone:
Fax:
WV Medicaid Provider #:
Office:
(
)
-
(
)
-
Clinical Contact Person:
Name of PCP:
Phone: (
)
-
TO- WHERE WILL PATIENT RECEIVE SERVICES?
Physician/Provider/Facility
Address:
Telephone:
Fax:
Requested:
(
)
-
(
)
-
Where services will be rendered? (Provide name of facility, if other than provider office or patient’s home)
WV Medicaid Provider #:
Today’s Date:
/
/
Tentative Date of Service/Admission:
/
/
Were member school based services interrupted?
Start Date:
/
/
YES
NO
End Date:
/
/
CLINICAL INFORMATION
ICD- 10 Codes: (required)
ICD- 10 Description:
1
2
3
4
CPT/HCPCS CODES: (required)
CPT/HCPCS Description:
1
2
3
4
Comments (list # Days/Visits/Units or if services are needed at discharge):
*DME, Therapies and Infusions must have Rx attached.*
CLINICAL INDICATIONS/RATIONALE FOR REQUEST:
To expedite a determination on your request for services, please attach clinical documentation/medical records to support your
request. Please include the following: Conservative treatment tried and failed, applicable diagnostic testing with results and lab
values and a medication list.
WV-16-06-01

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