Coventry Medical Prior Authorization Form PDF Details

Coventry Medical Prior Authorization Form is a document that provides information needed to get approval for Coventry Medicaid members before receiving certain services. It has two parts: the Request form and the Provider Forms section. The request form asks for relevant information about the patient's condition, diagnosis, treatment plan, medications, medical history, allergies, and who will authorize care. The provider forms section includes information on how to submit requests for authorization online or by mail with supporting documents such as prescriptions and lab reports. This blog post discusses Coventry Prior Authorization Forms, used to receive approval from insurance companies before receiving certain medical services.

Below are some details you might want to review before using the Coventry Medical Prior Authorization Form.

QuestionAnswer
Form Name Coventry Prior Authorization Form
Form Length 1 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 15 sec
Other names aetna coventry prior authorization form, aetna coventry medicare prior authorization form, coventry prior auth form, coventry health care prior authorization form

Form Preview Example

MEDICAL PRIOR AUTHORIZATION REQUEST

Fax the completed form to: North Florida Market (800) 929-5842 & Central/South Florida Markets (800) 528-2705 or call (888) 853-2629 for Summit/Advantra & (800) 447-3725 for Medicaid, Healthy Kids, Medicare, Commercial

Pr io r i t y :

cef

Stat (24 hours) cef Urgent Emergent (72 hours) cef Routine Request (4-14 days)

Pr od u ct :

cef

Commercial/Individual

fec Medicare cef Medicaid

cef Healthy Kids

Pr ov i d e r I n f o r m a t io n

 

Pa t ie n t I n f or m a t io n

 

Nam e:

 

 

Nam e:

 

Addr ess:

 

 

Mem ber I D:

 

Cit y , Zip Code:

 

 

DOB:

 

Phon e:

 

 

Dat e of Request :

 

Fax : ( Requ ir ed t o pr ocess aut hor izat ion )

 

 

 

Cont act Per son :

 

 

 

 

 

 

SERVICE REQUESTED: Fax Clinical / Plan of Treatment for Request

Ser vice Request ed:

 

 

DOS:

 

Diagnosis:

 

 

* I CD – 9 Code( s) : ( Requ ir ed t o pr ocess aut hor izat ion )

CPT Code( s) : ( Requ ir ed t o pr ocess aut hor izat ion )

Phon e Nu m ber :

 

Provider / Facilit y :

 

 

 

 

 

Addr ess:

 

 

 

 

 

Cit y , Zip Code:

 

 

 

 

 

Procedu re:

 

 

 

 

 

I npat ient Sur gery

 

Ou t pat ient Sur gery

 

Ot her

CLINICAL INFORMATION WITH SUPPORTING DOCUMENT(S)(Required to process authorization)

Prim ar y Care Phy sician Sign at u re:

 

 

SERV I CE PR OV I D ER I N ST RU CT I O N S

l

All fields in form MUST be com plet ed f or y ou r au t horizat ion t o be pr ocessed

l

Aut hor izat ion is not a guar an t ee of paym ent

l

Ver if y m em ber eligibilit y an d benef it s pr ior t o r ender in g ser vice

l

Subm it claim t o t he addr ess on t h e m em ber ’s I D car d

l

Specialt y n et w or k ph ysicians should f ollow net w or k guidelines

 

 

AUTHORIZATION APPROVAL(To be completed by the plan)

Aut hor izat ion # :

Dat e I ssued:

For m # 74 9VMPR

How to Edit Coventry Medical Prior Authorization Form Online for Free

Completing forms with this PDF editor is simpler when compared with most things. To edit coventry prior authorization form the document, there is nothing you have to do - just adhere to the steps down below:

Step 1: The initial step will be to select the orange "Get Form Now" button.

Step 2: As soon as you have entered your coventry prior authorization form edit page, you'll see all actions it is possible to undertake regarding your document at the top menu.

The following areas will make up your PDF file:

completing coventry advantra prior authorization phone number step 1

Fill in the CLINICAL INFORMATION WITH, Prim ar y Care Phy sician Sign at, SERV I CE PROV I D ER I N STRU CTI, l All fields in form MUST be com, AUTHORIZATION APPROVALTo be, Aut hor izat ion, Dat e I ssued, and For m VMPR section with the particulars required by the application.

stage 2 to finishing coventry advantra prior authorization phone number

Step 3: Press the "Done" button. Now, you may export your PDF file - save it to your device or send it through email.

Step 4: Make copies of the file. It will protect you from potential future complications. We don't read or distribute your data, hence be assured it is safe.

Watch Coventry Medical Prior Authorization Form Video Instruction

Coventry Medical Prior Authorization Form isn’t the one you’re looking for?

Related Documents

  • Cr A Form

    "... crane york city department of finance commercial rent tax return annual nyc gov finance 201011 applicable for the tax period june 12010 to may 312011 only 91 please print or typename employer identification number 11 social security number address number and street account type commercial rent tax account id city and state zip period beginning 060110 period ending 053111 business telephone number due date 062011 federal business code please read the instructions carefully so that you pay only the right amount of tax report full years rent or the annual zed rent if less than full year on this return complete this return by beginning with page check the type of business entity corporation partnership individual estate or trust check if applicable initial return business began on date amended return final return business discontinued on date total number of sub tenants computation of tax payment enclosed payment pay amount shown online make check payable to nyc department of finance rate no of premises total tax tax due line class for each rate class base rent rate total base rent tax rate from line 13 on pg or 10 to 249999 supplemental spreadsheet 0001000 from line 14 on pg or 2250000 and over supplemental spreadsheet 00623 tax credit from pg line 16 or supplemental spreadsheet see instructions 34 total tax due after tax credit line minus line 345 deduct total quarterly payments 56 balance due if line is less than line 467 add interest and penalties see instructions 78 over payment ..."

  • Colorado Form Cr 100

    "... Colorado Form Cr 100 ..."

  • Cp75A

    "... Department of the Treasury Internal Revenue Service Examination Operations Stop 826. ..."

  • Cpi Crs Form 13 146

    "... Pi crs Form 13 146 Revised 03 27 09 Page of Request for Contract Exchange Transfer from one vendor in the same 403 Plan to another vendor will not be permitted unless the vendor you ..."

Please rate Coventry Prior Authorization Form

1 Votes

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .