Boston Medical Center Healthnet is a company that specializes in healthcare information technology. Their goal is to provide an effective care delivery system for physicians, hospitals and consumers by assisting them with the management of electronic health records, patient scheduling, administrative tasks and more. They are committed to delivering high quality services through their innovative solutions which help improve the efficiency of medical practices around the world. Boston Medical Center Healthnet has been serving clients since 1989 and have become leaders in their field due to their commitment to customer satisfaction as well as continued innovation. Interested readers can visit bostonmedicalcenterhealthnet.com/blog or call 1-800-898-0662 for more information on our services today.
The listing provides details about the boston medical center healthnet. You'll have the assumed time it may require you to fill in the form plus some additional details.
| Question | Answer |
|---|---|
| Form Name | Boston Medical Center Healthnet |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Northwood, Modifier, DMEPOS, PCP |
MEDICAL PRIOR AUTHORIZATION REQUEST FORM
NOTE: PLEASE ATTACH SUPPORTING CLINICAL INFORMATION WITH ALL REQUESTS
INCOMPLETE INFORMATION MAY DELAY PROCESSING OF REQUEST
FAX TO:
.
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
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
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#
Provider line ph# 1
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