Clinical Review Pre-Authorization Request Form - Medicare


Clinical Review Pre-Authorization Request Form – Medicare
Member ID #:
Member Name:
Member DOB:
Requesting Provider:
Provider Office Contact Name:
Requesting Provider ID #:
Office Contact Phone # and Ext:
Tax ID #:
Office Contact Fax #:
Dates of Service:
Servicing Provider:
ICD-9*/ICD-10*/CPT/HCPCS Code(s):
* Services or inpatient discharges prior to Oct. 1, 2015 must use ICD-9 codes; services or inpatient discharges after Oct. 1, 2015 must use ICD-10 codes.
Fax Completed Form with Supporting Medical Documentation to Clinical Review at 1-866-706-6929
Services/Procedures Requested
Ambulance/medical transport (non-emergent)
Genetic testing
Pre-Authorization is required except for the following tests:
Cardiac monitoring (ambulatory ECG)
Chromosomal microarray analysis
Pre-Authorization is NOT required for standard holter monitors
Cystic Fibrosis – screening only
and loop event recorders.
Factor V Leiden
Clinical trial (copy of the patient consent is required)
FISH testing for diagnosis of lymphoma or leukemia
Fragile X
DME, including but not limited to:
Hereditary hemochromatosis
____ Bone growth stimulator
(photos required)
____ Power-operated wheelchair or scooter
Pulmonary Rehabilitation
____ Oral appliance for the treatment of sleep apnea
Reconstructive surgery
____ Other___________________________________
Transplant services except corneal
Ventricular Assist Device
Fax form and medical documentation to Clinical Review at 1-866-706-6929
To properly facilitate your request for Mammoplasty, please mail this form, medical documentation and photos to:
ConnectiCare, Attn: Clinical Review Department
175 Scott Swamp Road, Farmington, CT 06032-3124
Please Note:
Services are not considered authorized until ConnectiCare issues an authorization.
Failure to submit complete information will delay processing of request.
See separate forms to submit pre-authorization requests for Home Health Care, IV Therapy or Out-of-Network Services.
Please contact Clinical Review at 1-800-508-6157 (select option #1) with any questions about pre-authorization.
This is confidential information. If you receive this form in error, please notify Provider Services immediately at 1-877-224-8230.
Last reviewed 7/15


00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical