Outpatient Prior Authorization Fax Form

OUTPATIENT

855-764-8513

Complete and Fax to:

PRIOR AUTHORIZATION FAX FORM

Request for additional units. Existing Authorization

Units

Standard Request - Determination within 14 calendar days of receiving all necessary information

Expedited Request -I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening)

within 72 hours to avoid complications and unnecessary suffering or severe pain.

URGENT REQUESTS MUST BE SIGNED BY THE

X

REQUESTING PHYSICIAN TO RECEIVE PRIORITY.

*

INDICATES REQUIRED FIELD

*

Date of Birth

MEMBER INFORMATION

(MMDDYYYY)

*

Member ID/Medicaid ID

Last Name, First

REQUESTING PROVIDER INFORMATION

*

*

Requesting NPI

Requesting TIN

Requesting Provider Contact Name

Requesting Provider Name

Phone

Fax

SERVICING PROVIDER / FACILITY INFORMATION

Same as Requesting Provider

*

*

Servicing NPI

Servicing TIN

Servicing Provider Contact Name

Servicing Provider/Facility Name

Phone

Fax

AUTHORIZATION REQUEST

*

*

*

Primary Procedure Code

Additional Procedure Code

Start Date OR Admission Date

Diagnosis Code

(MMDDYYYY)

(CPT/HCPCS)

(Modifier)

(CPT/HCPCS)

(Modifier)

(ICD-10)

Additional Procedure Code

Additional Procedure Code

End Date OR Discharge Date

Total Units/Visits/Days

(CPT/HCPCS)

(Modifier)

(CPT/HCPCS)

(Modifier)

(MMDDYYYY)

*

OUTPATIENT SERVICE TYPE

(Enter the Service type number in the boxes)

412 Auditory Services

422 Biopharmacy

171

Outpatient Surgery

650

Radiation Therapy

299

Drug Testing

Outpatient Services

794

472

Stereotactic Radiosurgery

922 Experimental & Investigational Services

499

Transplants - Office Visit

DME

709

Genetic Testing

109

Transplants - Other Visit

417

Rental

799

Genetic Counseling

997

Office Visit/Consult (non par)

120

Purchase

249

Home Health

$

365

Office Visit/Vaccines & Administration

927

Outpatient Hospice

370

Office Visit/Dermatology Procedure

(Purchase Price)

Nutritional Supplements and/or services

290

Hyperbaric Oxygen Therapy

375

Office Visit/ Dental

407

Enteral Feedings

410

Observation

701

Speech Therapy

441

Parenteral Feedings

792

Vendor

101

Physical Therapy

360

Modified Solid Food Supplements

724

Transportation

790

Occupational Therapy

ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.

COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.

Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior

authorization as per Plan policy and procedures.

Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the

Rev. 07 08 2016

XZ-PAF-1126

intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document.