Standard Request - To promote more expedient turnaround times, please ensure all supporting documentation is attached. Our goal is to have a decision in less than 3 days. Requests received without medical records attached at the time of submission may take up the CMS allowed 14 days.

Request Priority

Standard RequestContinued Stay Review / Manual Submission

To Be Completed By Person Requesting Authorization

Name of Person Completing This Form?

Email Address for Person Completing This Form?

Phone Number for Person Completing This Form?

Fax Number for Person Completing This Form?

Additional Contact Info?

Requester Tax ID

Patient Information

Member First Name

Member Last Name

Member Date of Birth

Member Health Plan ID

Requested Services Inpatient/Observation

Primary Diagnosis Code (ICD-10)

Other Diagnosis Codes (ICD-10)

Requested Services

Post-Acute Skilled Nursing Serv. (Transfer From Hospital Inpatient Stay For Initial SNF, LTAC, IRF)Skill In Place (Member's Nursing Facility Use Only)Acute Inpatient Stay (Unplanned)Inpatient (Planned/Preservice)Observation StayLTAC - Long Term Acute CareIRF - Inpatient Rehab FacilityContinued Stay Review (Use Only When Initial Review Has Been Completed)Other

Procedure Code(s) Requested (CPT/HCPCS/REV Code). Use a comma to separate.

Requested Services Outpatient/Office/Home/Other

Procedure Code(s) Requested (CPT/HCPCS/REV Code). Use a comma to separate

Primary Diagnosis Code (ICD-10)

Other Diagnosis Codes (ICD-10)

Hospice

Provider Name:

Provider NPI

Provider Phone Number

Admit / Discharge Dt:

Skill In Place

Number of Days Requested

Reason (Include indications for SIP i.e. WBC 15,000, Fever 102.6, COVID Positive with Cough and Fever 101)

Post-Acute

Procedure Code(s) Requested (CPT/HCPCS/REV Code). Use a comma to separate.

Number of Days Requested

Reason? (Please indicate what qualifies this member to receive this level of post-acute care i.e. WBC count of 15,000, temp of 103, decline from baseline functional status.)

Referral

Referral Type

Specialist ReferralConsult Only (one time visit)

Reason for Specialist Referral

New Member Needing Continuity of ServicesExisting Member With Established Treatment PlanTreatment/Services Not Available with In Network ProviderOther

Please provide any additional notes that would be useful in reviewing this request.

Referred To Provider Name

Referred Provider Appointment date

Transportation

Transportation Provider Name

Procedure Code(s) Requested (CPT/HCPCS/REV Code). Use a comma to separate.

Transportation Provider Phone

Reason for Transport?

Other Services

Requested Procedure Codes (HCPCS/CPT/Rev Codes)

Please enter a description of the services being requested.

Provider Information - Inpatient - Acute/Observation

Admit Date

Servicing Facility Name

Servicing Facility NPI

Admitting Provider Name

Admitting Provider NPI

Servicing Provider Name (If different from Ordering Provider)

Servicing Provider NPI (If different from Ordering Provider)

Provider Information - Inpatient - Planned IP Admit

Admit Date

Servicing Facility Name

Servicing Facility NPI

Ordering Provider Name

Ordering Provider NPI

Servicing Provider Name (If different from Ordering Provider)

Servicing Provider NPI (If different from Ordering Provider)

Provider Information - Inpatient - Post Acute

Admit Date

Sending Provider Name

Sending Provider NPI

Sending Facility Name

Sending Facility NPI

Accepting Facility Name

Accepting Facility NPI

Accepting Provider Name

Accepting Provider NPI

Provider Information - Inpatient - Skill In Place

Admit Date

PCP Name

PCP NPI

Facility Name

Facility NPI

Ordering Provider Name

Ordering Provider NPI

NP order for "Skill In Place" MUST be signed, dated, and timed (authenticated) to ensure timely turnaround. Please indicate where the order can be reviewed by UM RN:

Copy of authenticated NP order will be attached to this request.Copy of authenticated NP order is available in EHR (i.e. MatrixCare).

Provider Information - Outpatient/Office/Home/Other

Ordering Provider Name

Ordering Provider NPI

Servicing Provider Name (if different from ordering)

Servicing Provider NPI

Servicing Facility Name (if applicable)

Servicing Facility NPI/TIN

Medical Records

Note: To prevent submission errors please ensure the records have been attached for review. An error will display, and your request will not be submitted without supporting documentation attached. Also, please ensure that if you selected “Add another response” and it is no longer needed that you remove those fields prior to submission by clicking “Remove”.

: Please attach any relevant medical records or supporting :

Request for Services - Prior Authorization

To Be Completed By Person Requesting Authorization

Patient Information

Requested Services Inpatient/Observation

Requested Services Outpatient/Office/Home/Other

Hospice

Skill In Place

Post-Acute

Referral

Therapy Request

Transportation

DME

Other Services

Provider Information - Inpatient - Acute/Observation

Provider Information - Inpatient - Planned IP Admit

Provider Information - Inpatient - Post Acute

Provider Information - Inpatient - Skill In Place

Provider Information - Outpatient/Office/Home/Other

Medical Records