Mississippi Prior Authorization Fax Request Form
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1Mississippi Prior Authorization
Fax Request Form 888-310-6858
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_____________________________________
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Telephone #: ___________________ Fax #: _____________________Is this a HIPAA secure fax line?
Yes
No
Requesting Provider: ________________________________ Telephone #: _________________________
Requesting Provider TIN/NPI: __________________________
Type of Request:
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Routine
Urgent
Urgent is defined as “significant impact to health of the member”
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Expedited (Medicare Only) Request from physician only, defined as “waiting for a decision under
standard timeframe could place the member’s life, health or ability to regain maximum functionality or
would cause serious pain”
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: ____________
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Is member Pregnant?
Yes
No
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Is request related to MVA or work-related injury?
Yes
No
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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)
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If Non-par will provider accept Medicaid/Medicare default rate -
Yes
No
Type of Service:
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DME – Purchase/Rental
Cosmetic or Reconstructive
Home Health/Hospice Services
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Outpatient/SDS
Surgery
Skilled Nursing Facility
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Prosthetic / Orthotics
PT / OT / ST
Hysterectomy/Abortion/Sterilization
□
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Inpatient Elective Surgery
MRI, MRA or PET Scan
Out Of Network (please explain)
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Transplantation Evaluation
Gastric Bypass Eval/Surgery
Other _____________________
Clinical Information:
Diagnoses:___________________________________ICD-9 Codes: ______________________________
CPT/HCPCS Codes: _________________________________DME Pricing_________________________
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
02/09/11
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