Louisiana Prior Authorization
Fax Request Form
877-271-6290
Please complete all fields on the form, and refer to the listing of services that require authorization. The list
can be found at
Date: _____________________
Contact Person_____________________________________
Telephone #: ___________________ Fax #: _____________________Is this a HIPAA secure fax line?
□
Yes
□
No
Requesting Provider: ________________________________ Telephone #: _________________________
Requesting Provider TIN/NPI: __________________________
Type of Request:
□ Routine □ Urgent
Urgent is defined as
“Medical care provided for a condition that without timely
treatment, could be expected to deteriorate into an emergency, or cause prolonged,
temporary impairment in one or more bodily function, or cause the development of a
chronic illness or need for a more complex
treatment”
For Expedited or Urgent cases, the preferred method of contact is by phone. Please call request to 866-604-
3267.
Member Information:
Member Information:
Member Name: _______________________Member ID/JD#______________________ Date of Birth: ___________
Is member Pregnant?
□
Yes
□
No
Is request related to MVA or work-related injury?
□
Yes
□
No
Does member have other insurance?
□
Yes
□
No
Medicare
□
Part A
□
Part B
Other insurance name and policy #__________________________________________________________________
Servicing Provider Information:
Servicing Provider: __________________________________
TIN/NPI _____________________________
Address: _______________________________________
Fax #: ______________________________
Date of Service:_________________________________________ PAR or Non-PAR (please circle one)
If Non-par will provider accept Medicaid/Medicare default rate -
□
Yes
□
No
Type of Service:
□
Outpatient/SDS
□
Cosmetic or Reconstructive
□
Home Health/Hospice Services
□
Inpatient Elective Surgery
Surgery
□
Hysterectomy/Abortion/Sterilization
□ Transplantation Evaluation
□
PT / OT / ST
□
Other _____________________
□
MRI, MRA or PET Scan
□
Out Of Network (please explain)
□
Transplantation Evaluation
□
Gastric Bypass Eval/Surgery
Clinical Information:
Diagnoses:___________________________________ICD-9 Codes: ______________________________
CPT/HCPCS Codes: _________________________________
Procedures: ____________________________________________________________________________
Number of visits:_______________ Duration:____________________ Frequency: ____________________
Number of previous visits: _________________ Service name/code for previous visits: ________________
NOTE: In order to process your request completely and timely, submit any pertinent clinical data (i.e. progress notes, treatment
rendered, tests, labs results, radiology reports) to support request for services. Any request for OON services must include
documentation on the reason for the request along with the name of the OON provider. FAILURE TO PROVIDE SUFFICIENT
INFORMATION WILL RESULT IN A DELAY IN YOUR REQUEST.
UnitedHealthcare Community Plan
11/28/11