Coventry Medical Prior Authorization Form PDF Details

Navigating the complexities of healthcare requirements demands a clear understanding of the necessary procedures and documentation—key among these is the Coventry Prior Authorization form. This crucial document acts as a gateway for patients and healthcare providers to secure approval for certain medical services before they are rendered. Aimed at facilitating transactions within the North Florida and Central/South Florida markets, the form encompasses a wide array of services by requiring detailed patient and provider information, including member ID, date of birth, and the specific service requested. Further, it classifies requests based on urgency—ranging from Stat (within 24 hours) to Routine (between 4-14 days)—and by patient affiliation, whether Commercial/Individual, Medicare, Medicaid, or Healthy Kids. Every request must be accompanied by pertinent clinical information and documentation to support the authorization process, emphasizing the importance of completeness for timely processing. The form also delineates clear instructions for service providers, underscoring that authorization does not guarantee payment and highlights the necessity of verifying member eligibility and benefits prior to service rendering. In addition, it provides guidelines for submitting claims and outlines the specialty network physicians' procedures, culminating in the authorization approval section completed by the plan, including authorization number and issue date. This structure ensures that all parties involved have a transparent understanding of the requirements and process, facilitating smoother operations and contributing to the overall efficiency of healthcare service provision.

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

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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.

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