Access Medicare Requests For Outpatient Authorization
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1Access Medicare
Requests for Outpatient Authorization
Please note all fields must be filled in for request to be processed. Please fax to (646)-417-5246 and a
Medical Management representative will contact you within three business days.
Member’s Name:
Member’s ID #:
Provider Name or ID#:
Dx Code(s):
HCPCS/Procedure Codes and Number of Units Being Requested :
CPT/HCPCS
Mod
Units
CPT/HCPCS
Mod
Units
CPT/HCPCS
Mod
Units
Contact Name and Phone Number:
Place of Service Please check the correct choice.
____ Outpatient clinic
____ Ambulatory surgery
____ Member’s home
____ Office
____ DME
What type of Service requested? Please check the correct choice.
____ Home Health Care
•
____ Outpt PT, ST, OT
PT, ST & OT initial 12 visit no medical documentation required.
th
Subsequent visit after the 12
visit will require Medical documentation.
____ Ambulatory surgery
•
Mental Health initial 6 visit no medical documentation required.
____ Subsequent Mental Health
th
Subsequent visit after the 6
visit will require medical documentation.
____ Detox, Chemical Dependency
____ MRI/MRA
For all services listed you must provide a letter of
____ Nuclear Medicine
medical necessity and supporting documentation. The
____ Radiation Therapy
authorization request cannot be processed without it.
Start of Care
________/_______/_______
End of Care
_______/_______/________
For Internal Access Medicare Use Only
Authorization Number :
Pending Authorization NBR/Case Manager Name
*Faxing this form is only a request and not an approval for the service.
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Parent category: Medical