Form Nofr001 - Texas Standard Prior Authorization Request Form For Health Care Services Page 2

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T
S
P
A
R
F
H
C
S
EXAS
TANDARD
RIOR
UTHORIZATION
EQUEST
ORM FOR
EALTH
ARE
ERVICES
Clear Form
Print
S
I — S
ECTION
UBMISSION
Issuer Name:
Phone:
Fax:
Date:
Magellan Healthcare, Inc. (for HMO Blue Texas)
800-279-2422
888-656-5712
S
II — G
I
ECTION
ENERAL
NFORMATION
Review Type:
Non-Urgent
Urgent
Clinical Reason for Urgency:
Request Type:
Initial Request
Extension/Renewal/Amendment
Prev. Auth. #:
S
III — P
I
ECTION
ATIENT
NFORMATION
Name:
Phone:
DOB:
Male
Female
Other
Unknown
Subscriber Name (if different):
Member or Medicaid ID #:
Group #:
S
IV ― P
I
ECTION
ROVIDER
NFORMATION
Requesting Provider or Facility
Service Provider or Facility
Name:
Name:
NPI #:
Specialty:
NPI #:
Specialty:
Phone:
Fax:
Phone:
Fax:
Contact Name:
Phone:
Primary Care Provider Name (see instructions):
Requesting Provider’s Signature and Date (if required):
Phone:
Fax:
S
V ― S
R
(
CPT, CDT,
HCPCS C
)
S
D
(
ICD C
)
ECTION
ERVICES
EQUESTED
WITH
OR
ODE
AND
UPPORTING
IAGNOSES
WITH
ODE
Planned Service or Procedure
Code
Start Date
End Date
Diagnosis Description (ICD version___)
Code
Inpatient
Outpatient
Provider Office
Observation
Home
Day Surgery
Other: __________________
Physical Therapy
Occupational Therapy
Speech Therapy
Cardiac Rehab
Mental Health/Substance Abuse
Number of Sessions: ___________ Duration: ________________ Frequency: ___________ Other: _______________________
Home Health (MD Signed Order Attached?
Yes
No)
(Nursing Assessment Attached?
Yes
No)
Number of Visits: _____________ Duration: ________________ Frequency: ___________ Other: _______________________
DME (MD Signed Order Attached?
Yes
No)
(Medicaid Only: Title 19 Certification Attached?
Yes
No)
Equipment/Supplies (include any HCPCS Codes): _____________________________________ Duration: __________________
S
VI ― C
D
(S
I
P
, S
VI)
ECTION
LINICAL
OCUMENTATION
EE
NSTRUCTIONS
AGE
ECTION
An issuer needing more information may call the requesting provider directly at: _______________________________________
NOFR001 | 0415
Page 2 of 2

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