Medical Pre-Authorization Request Form
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1
2MEDICAL PRE-AUTHORIZATION REQUEST
Used for Coventry Health Care of Florida Members
800-528-2705
Fax the completed form to the Pre-Authorization dept. at
or call (888) 853-2629 for Summit, Advantra and
(800) 447-3725 for Medicaid, Vista Medicare, Commercial, or Individual Members
Priority:
Stat (24 hours)
Urgent Emergent (72 hours)
Routine Request (4-14 days)
Product:
Commercial/Individual
Medicare
Medicaid
Healthy Kids
PROVIDER INFORMATION
PATIENT INFORMATION
Name
Name
Address
Member ID#
City, Zip Code
DOB
Phone
Date of Request
*Fax (Required to process authorization)
Contact Person
SERVICE REQUESTED: Fax Clinical / Plan of Treatment for Request
Service Requested
DOS
Diagnosis
*CPT Code(s) (Required to process authorization)
*ICD – 9 Code(s) (Required to process authorization)
Provider / Facility
Phone
Address
City, Zip Code
Procedure
Inpatient Surgery
Outpatient Surgery
Other____________________________
*CLINICAL INFORMATION WITH SUPPORTING DOCUMENT(S)
(Required to process authorization)
Primary Care Physician Signature:_____________________________________________________________
SERVICE PROVIDER INSTRUCTIONS
•
All fields in form MUST be completed for your authorization to be processed
•
Authorization is not a guarantee of payment, verify member eligibility and benefits prior to rendering service
•
Submit claim to the address on the member’s ID card
•
Specialty network physicians should follow network guidelines
AUTHORIZATION APPROVAL (To be completed by the plan)
Authorization #
Date Issued
Form #749VMPR
Rev 8 07/30/2010
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Parent category: Legal