MEDICARE PRIOR AUTHORIZATION REQUEST FORM
All REQUIRE MEDICAL RECORDS TO BE ATTACHED
Phone: 855-969-5884 Fax: 813-513-7304
Instructions:
This form is for prior authorization requests which will be processed as quickly as possible depending on the member’s health condition.
IMMEDIATE OR EXPEDITED REQUESTS: Do not write STAT, ASAP, Immediate on this form. Please follow below instructions.
Medicare’s definition of expedited is defined as one where “applying the standard time for making a determination could seriously jeopardize the life
or health of an enrollee or the enrollee’s ability to regain maximum function.”
Complete this section for expedited requests ONLY.
If your PHYSICIAN feels the member meets the definition of expedited above, have your physician document his/her reason below:
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Complete remainder of form for ALL requests.
Member Information
Name:______________________________________________ Date of Birth: ______________ Plan ID#: _________________
Requesting Provider Information
Requesting provider name: ______________________________________________________ TIN#: _____________________
Phone: (____)_____________ Fax: (____)_____________ Contact Person:_____________________________ Ext.________
Please provide a short clinical statement to support your request:
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Facility Requested (No Abbreviations)
Provider Requested (No Abbreviations)
Name: _____________________________________________ Name: _____________________________________________
TIN#: ________________________________
□ Non-Par
TIN#: ________________________________
□ Non-Par
Phone: (_____)_____________ Fax: (_____)______________ Phone: (_____)_____________ Fax: (_____)______________
Date of Service:
Diagnosis:
Diagnosis:
Service Requested: Check appropriate request(s)
□ Abortions
□ Genetic Testing/Blood Products
□ Acute Rehabilitation Facility
□ Home Health Services
□ ASC for Blepharoplasty, Podiatric Surgery,
□ Hospice ** Notification only
Reduction Mammoplasty, Rhinoplasty,
□ Hyperbaric Oxygen Therapy
Septoplasty, Vein treatments, Ocular Surgery,
□ Implantable pump/device or stimulator
Pain Management Injections, Plastic Surgery only
□ Injectables/Infusion Therapy
□ Chemotherapy
□ Inpatient Hospital
□ Clinical Trials
□ Medical Nutrition Education
□ Cosmetic Procedures
□ MOHS Procedure (Dermatology)
□ Diabetic Education
□ Non-Participating Provider
□ Dialysis
□ Obstetrical Care
□ DME/Orthotics/Prosthetics > $500 (see * below)
□ Outpatient Hospital
□ Enteral Feedings
□ Pain Management
□ Experimental/Investigational Procedure
CPT or HCPC Code(s)
Description
ICD-9 Code(s):
ICD-9 Code(s):
□ Radiation Therapy
□ Radiology/Diagnostic Tests: CT, CTA, MRA, MRI, Nuclear Med Cardiac, PET, Pill, MUGA, Radiation
Oncology, Medical Oncology, Virtual Colonoscopy or Endoscopy and 3D Ultrasound
□ Rehab Cardiac/Pulmonary/Respiratory
□ Rehab Therapy (PT, OT, SP) any outpatient hospital and any office therapy > than 10 visits.
□ Skilled Nursing Facility
□ Sterilizations
□ TMJ Joint treatment
□ Transplant
□ Wound Care (outpatient hospital only)
# of Visits/Injections
*DME > $500 if purchased or > $38.50 per month if rented. Includes all wheelchairs, hospital beds, CPAPs, BiPAPs, nerve and bone growth stimulation devices
and oxygen, as well as TENS devices, wound care/wound vacuums and related supplies, repairs, miscellaneous codes and all Medicare non-covered items.
Prominence Health Plan Prior Authorization Request Form 2015