Prior Authorization Requests Form - Keen Transport printable pdf download

Prior Authorization Requests Form - Keen Transport

Prior Authorization Requests for Members of the

Keen Transport, Inc. Benefit Plan

Patient name: ___________________________ DOB: __________________________

ID#: ___________________________________ Group: _________________________

Insured name: ___________________________

Provider name: __________________________ Provider phone:__________________

Contact name: ___________________________ Provider fax: ____________________

________________________________________________________________________

Diagnosis Codes: __________________________________________________________

CPT Codes: ______________________________

Include:



All medical records including actual office notes & treatment history.



All applicable lab reports.



All applicable radiology reports



Indicate other providers’ names & contact information who have beeninvolved in

diagnosis & treatment for same diagnosis.

Please note that all benefits for approved expenses will be considered at the lower of a) the

network’s provider discounted price, b) the maximum the patient is required to pay, c) the

result of an objective and independent valuation study performed by an outside reviewer

approved by the Plan Administrator or d) 200% Medicare approved amount for the services

performed, or e) for drugs, 110% of the Average Sales Price (ASP).

Please sign below that this benefits acknowledged and that the patient will only be billed for

the copays, deductibles and co0insurance costs.

______________________________

_________________

Name of Representative

Date

*With respect to scheduling services, allow 2 weeks for the review process once complete

documentation is received by the consultant.

Send this completed form & all supporting documentation to 713 592‐6112.

Prior Authorization Requests Form - Keen Transport