Pre Authorization Form
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1Pre Authorization Form
800-470-2004
Please send this completed form along with all pertinent clinical documentation to Coventry Health Care of
Georgia, Inc. Medicare should be sent to 855-799-8262 (fax); all other plans to 866-599-3720 (fax) or you may
submit online:
Office Contact Name: _____________________________________________________________________________
Office Contact Phone #: _________________________ Office Contact Fax #: _____________________________
Total Number of Pages (including cover page): ________________________________________________________
Patient Information
Requesting Provider Information
Name (Last, First, MI)
Provider Name
Provider Specialty
Member ID #
*
Date of Birth ____ / ____ / ____
Tax ID #
Other Insurance
Provider Address
Phone #
Fax #
Service/Procedure Requested
Diagnosis
Procedure
ICD-9 Code
Description
CPT Code
Description
HCPCS Code
Description
Place of Service:
Inpatient
Outpatient
Observation
Office
Home
Facility Name:
Tax ID#:
Date of Scheduled Admission/Procedure:
Date of Surgery (if different than admission date):
The ordering physician has the option of requesting reconsideration by faxing additional clinical information to the
appropriate fax number listed above or by requesting an MD/MD consult within 2 business days by calling
800-470-2004, option 6, Extension # (type in your extension). If your request is for a spinal, please note all cages
require precertification.
NOTICE TO PROVIDERS AND MEMBERS
If Hospitalization, Outpatient Surgery or Extension of Visits is needed, call Health Services, 800-470-2004.
Reimbursement for services is subject to member eligibility and benefit coverage at the time of service and authorization.
Health Plan may reduce or deny payment for services which are not billed or coded in accordance with generally accepted industry standards and may
use industry accepted software to edit claims to ensure appropriate billing and coding practices.
Referral does not carry a guarantee of payment.
***************************************************************************************************************************************
Coventry Office Use Only
Approved
Authorization Number: ________________________ Expiration Date: ______________________________
Number of Visits Authorized: ___________________ Date: _______________________________________
Denied
Denial Rationale:
Reviewer
YD/clt 03.25.14
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