MEDICAL PRIOR AUTHORIZATION REQUEST FORM
NOTE: PLEASE ATTACH SUPPORTING CLINICAL INFORMATION WITH ALL REQUESTS
INCOMPLETE INFORMATION MAY DELAY PROCESSING OF REQUEST
FAX TO: 617-951-3464 - initial requests; 617-951-3461 - additional clinical; 617-951-3463 - emergency and inpatient
.
Member Information
Member Name: _______________________________________________ DOB: ____________ BMCHP ID #: ____________________
Submitted by / Sender Information
Submitted by: ___________________________________________ Phone # (direct line): ________________ Fax #: _______________
Who sent in the form?
Provider Information
Requesting Provider Name: ____________________________________________ NPI #: ____________________ PCP Specialist
Servicing Provider/Group Name: _____________________________________/_____________________ NPI #: ___________________
Individual’s name and group name if affiliated with multiple groups
Servicing Provider Address: _____________________________________________ Phone #: ________________ Fax #: ____________
At what address will member be seen?
Servicing Facility Name:_____________________________________________________________ NPI #: _______________________
Requested Services
Office Visit / Consult: Primary Care OB: EDC (required) ____________ Specialist: Type: ___________________________
Visit Date: Scheduled: _________ Most Recent: _________ # Visits: _____ Required Codes: Diagnosis: __________ CPT: _________
Surgery: Inpatient Outpatient Post-op Observation: _______hours Scheduled date: _______________
Required Codes: Diagnosis: _______________ CPT: _______________
Outpatient Rehab: PT: # visits ______ Date range: ________________ OT: # visits _____ Date range: ________________
ST: # visits ______ Date range: ________________
Required Codes: Diagnosis: _______________ CPT: _______________
Home Health Care: RN: # visits _______ |
Date range: ____________ |
PT: # visits _________ |
Date range: ____________ |
OT: # visits _______ |
Date range: ____________ |
ST: # visits _________ |
Date range: ____________ |
SW: # visits _______ Date range: ____________ |
HHA: # visits _______ |
Date range: ____________ |
Other: _________ # visits _______ Date range: ____________
Specify type
Required Codes: Diagnosis: _______________ CPT: _______________
DMEPOS**: HCPCS Code Modifier DescriptionQuantity (Units/Calories) Cost
___________________________________________________________________________________________
___________________________________________________________________________________________
**For DMEPOS provider requests and requests for oral enterals by any provider, contact Northwood at 866-802-6471 for authorization.
Additional Comments:
The number you will receive from the BMC HealthNet Plan Prior Authorization Department is a reference number; it is not a guarantee of payment. Payment is based upon eligibility of the member on the date of service, verification of the service as a covered benefit, and medical necessity. Submission of cost or charge information does not guarantee payment at those rates.
Member service ph# 1-888-566-0010 (MassHealth); 1-877-957-5300 (Commonwealth Care); 1-877-492-6967 (Commercial)
Provider line ph# 1 -888-566-0008
