Out Of Network Prior Authorization Request Form
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1OUT OF NETWORK PRIOR AUTHORIZATION REQUEST
PROTECTED
INFORMATION TO BE COMPLETED BY REFERRING PHYSICIAN OFFICE – Please PRINT
Members Who have NOT transitioned to UNET - Fax to 888-242-9058 / Members Who Have Transitioned to UNET - Fax to 866-756-9733
Call if Questions: 800-747-1446, ext. 65212
Date Submitted : _________________________
Are the Services Requested Urgent or Emergent Medical Services?
Yes
No
Patient Name: ___________________________________________ Subscriber #____________________________________ DOB: _____________
Member Preferred Contact Number:_____________________________________________________________
Physician Office Referral Contact: ________________________ Phone#: (________)_____________________ FAX#: (_______)____________________
Name of Requesting Physician: _______________________________________________ Specialty: _______________________________________
Name of Specialist Referred To: __________________________________________________ Specialty: _______________________________________
Facility/Clinic Name: ____________________________________________________________ City, State_______________________________________
Place of Service: ______Office _____Outpatient Facility _____Inpatient __________________________________________
Other (define)
DIAGNOSIS/DIAGNOSIS CODE(S):
PROCEDURE/CPT CODE(S):
REASON FOR REFERRAL: Services not available within network; Patient Preference; Other (Describe): _______________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
APPLICABLE LAB/X-RAY/IMAGING ALREADY COMPLETED (List):_____________________________________________________________________
____________________________________________________________________________________________________________________________
HAS TREATMENT BEEN INITIATED?
Yes
No
PATIENT’S RESPONSE: _______________________________________________________
____________________________________________________________________________________________________________________________
H
?
Yes
No
(Attach Consultation Report)
AS THE PATIENT BEEN EVALUATED PREVIOUSLY BY A NETWORK SPECIALIST
-
-
?
Yes
No
(Attach Consultation Report)
HAS THE PATIENT BEEN EVALUATED PREVIOUSLY BY AN OUT
OF
NETWORK PROVIDER
REQUESTED DURATION OF REFERRAL SERVICES: From Date: _____________________ To Date: _______________________ # Visits: _______
S
R
(Check all that apply):
Consult
Diagnostic Testing
Medical Treatment
Surgical Treatment
ERVICES
EQUESTED
PERTINENT
P
APPOINTMENT DATE (if known): _________________________
LEASE FAX ANY
RECORDS
*** TO BE COMPLETED BY UHC STAFF ONLY ***
FACETS #_________________________
APPROVED
From Date: ______________________________ To Date: _______________________________ # Visits:___________ (if applicable)
UM Service Group:
ODON
OCON
OCOM
OCOD
OMED
OMON
OMOS
OCOS
OSON
OSUR
ASA
Comments_________________________________________________________________________________________________________________
DENIED
REASON FOR DENIAL:
Services Available in Network
Other _______________________________________________________
____________________________________________________________________________________________________________________________
Date/Time Requesting Physician Notified: Phone/Fax ________________________________________ If by PHONE Contact _______________________
Referral Contact: ________________________________________ Physician Reviewer Initials _______ Date & Time__________________________
E
G
# __________ R
P
_________ P
:
S
C
S
P
T
C
POS:
Yes
No
MPLOYER
ROUP
ISK
OOL
RODUCT
ENIOR
ARE
ECURE
LUS
ENN
ARE
REFERRAL NOTIFICATION LETTERS TO PHYSICIANS AND PATIENT TO FOLLOW
UCSMM.URV.06.14.A1
Last Reviewed: 4/13; 5/14; 4/16
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Parent category: Medical