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PA For Chiro

This document is a prior authorization request form containing sections for member information, ICD-10 diagnosis codes, procedure/service details, provider information, and general comments. It includes fields for member name, DOB, address, phone number, diagnosis codes, place of service, CPT/HCPCS codes, cost of DME, modifiers, number of units, service dates, requesting and servicing provider details, contact names, phone and fax numbers.

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38 views

PA For Chiro

This document is a prior authorization request form containing sections for member information, ICD-10 diagnosis codes, procedure/service details, provider information, and general comments. It includes fields for member name, DOB, address, phone number, diagnosis codes, place of service, CPT/HCPCS codes, cost of DME, modifiers, number of units, service dates, requesting and servicing provider details, contact names, phone and fax numbers.

Uploaded by

yjj856765
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Prior Authorization Request Form

Fax #: 808.973.0676 (Oahu) Fax #: 808.944.5611 Fax #: 888.881.8225 Fax #: 800.267.8328


888.667.0680 (NI) Phone #: Phone # for Expedited: Phone #: 888.980.8728
Phone #: 808.973.0712 808.948.6464 (Oahu) 888.505.1201 (Medicare) Website:
Website: www.alohacare.org 800.344.6122 (NI) 888.846.4262 (Medicaid) Healthcare Provider
800.877.5394 (Mainland) Website: provider.wellcare.com Resources-
Website: hhin.hmsa.com UHCprovider.com
For Medicare and Medicaid plans: decision & notification are made within 14 calendar days*

■ Standard request For HMSA Commercial, Federal and EUTF plans: decisions & notification are made within 15 calendar days*
Decision & notification are made within 72 hours* or as expeditiously as this member’s health condition requires if urgent
 Expedited request criteria are met.
(MD, PA, RN, RD or LPN)
Signature required) By signing below, I certify that following the standard timeframe could seriously jeopardize this member’s life or health or
ability to attain, maintain, or regain maximum function.

Signature (if left blank, request will be reviewed based on standard timeframes) Date signed

 Retrospective Retrospective authorization is defined as a request for services that have been rendered but a claim has not been submitted.
*From receipt of request, provided that all relevant supporting clinical information and documentation are submitted.
To avoid delays, please attach supporting documents
A. Member information
Jin, Yon Jeong 11/06/1996
Membership ID Patient’s Name (Last, First MI) Date of birth (MM/DD/YYYY)
2211 Ala Wai Blvd, Apt 2710, Honolulu, HI 96815 (919) 381-2334
Member’s Physical Address Phone #

B. ICD-10-CM diagnosis code(s)

Diagnosis code(s):
C. Procedure/service/treatment information
Place of service: Inpatient Outpatient/ASC (ambulatory surgical center) Labs and diagnostic (outpatient) Office Home
For Rehab Services (check one): PT OT Speech Initial Continuing Last Date of Service: ___________ Total Visits Used:________
CPT/HCPCS code(s) Cost of DME Modifier # of units CPT/HCPCS code(s) Cost of DME Modifier # of units

Service date(s): to Hospital Discharge


D. Provider information

Requesting (or referring) provider name Provider ID/NPI/TIN

Address

Contact Name Phone No. Fax No.

Servicing Provider/Facility/Vendor (if different from requesting or referring provider) Provider ID/NPI/TIN

Address

Contact Name Phone No. Fax No.


E. General Comments

PriorAuth.Allplan_Form 01/01/2023

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