Are you having difficulty getting the treatment and care your doctor recommends for an illness or injury? If so, you may need to file a health plan appeal to get the coverage you require. Understanding how this process works can help ensure that your rights are protected and that you have a chance at receiving the medical care needed to restore your health. In this blog post, we will discuss what an appeal is, why they’re important when dealing with insurance issues, and tips on navigating the form involved in submitting one.
| Question | Answer |
|---|---|
| Form Name | Health Plan Appeal Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | driscoll childrens chips appeal form, driscoll health plan prior authorization form, driscoll prior authorization form pdf, driscoll health plan authorization phone number |
Texas Referral/Authorization Form
Please fill out form completely in blue or black ink. Refer to instruction sheet.
This referral does not guarantee payment. Please contact health plan to verify member eligibility and covered benefits.
❏CHIP ❏ STAR/Medicaid ❏ OTHER_____
HEALTH PLAN NAME: |
________________________ DATE ____/____/____ |
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Health Plan Fax# |
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PATIENT INFO. |
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Patient name ______________________________________________________________ |
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LAST |
FIRST |
MIDDLE INITIAL |
DOB ______/________/______ Sex M❏ F❏ Phone # (____)____________________ |
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Member ID #____________________ Member Social Sec. # |
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OPTIONAL |
REFERRED BY |
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Physician name __________________________________________________________ |
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LAST |
FIRST |
M.I. |
Provider # _________________________________ |
❏ PCP ❏ SCP ❏ HOSPITAL |
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Fax # (______)____________________
Contact name __________________________ Phone # (_____)_________________
REFERRED TO
Provider name ____________________________________________________________
LASTFIRSTM.I.
Specialty type ___________________________ Provider/Facility # _________________
Fax # (_____)____________________ Phone # (_____)_______________________
Provider City ____________________________, Texas
REFERRED TO LOCATION
❏Office ❏ Outpatient facility*** ❏ Inpatient ❏ 23 Hour observation
***Note for outpatient facility, List CPT4 at right
❏ ER/Post Stabilization ❏ Other Date of service _______/________/______
Facility name _____________________________________________________________
Facility # * _____________________________* Required for ER/UCC, Therapy and Outpatient services.
COMMENTS/CLINICAL HISTORY __________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Clinical information attached: |
❏ Y / N ❏ |
# of pages _____ |
PHYSICIAN SIGNATURE- |
_________________________________________________ |
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The information contained in this form is privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited If this communication has been received in error, the reader shall notify sender immediately and shall destroy all information received.
HEALTH SERVICES RESPONSE
❏ Approved as requested |
Authorization # ___________________ |
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Expiration date ______/______/______ |
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Days authorized _____ |
❏ROUTINE ❏ URGENT
❏EMERGENCY
❏OUT OF NETWORK
❏REVISED REFERRAL
❏NOTIFICATION ONLY
Requested
Start date ____/_______/_______
Requested
End date _____/_______/_______
______________________________
Scope of referral
❏Consultation
❏Diagnostic Testing
❏
Number of visits _____
SPECIFIC SERVICES REQUESTED**
**Refer to specific plan instructions.
Certification/authorization guidelines must be followed.
❏Behavioral Health
❏Dialysis
❏DME/Prosthesis/Supplies
❏Case Mgmt. ___________________
_____________________________
❏Health Educ. __________________
_____________________________
❏Home Care
❏Injections and IV Therapy
❏Maternity Services:
EDC ________________________
❏ Vaginal ❏
❏Lab/Pathology
❏Radiology/ Imaging
❏Therapy: Indicate # of visits ________
❏Physical ❏ Cardiac Rehab
❏Speech ❏ Occupational Visits/Week _____
❏Surgery ____________(CPT4 code)
❏Assistant Surgeon
TO AUTHORIZE ONLY (OR OTHER) SPECIFIC SERVICES, INCLUDE CPT4 /MEDICAID LOCAL OR HCPCS CODES HERE.
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❏ Medical Director Review ❏ Pending Info. ❏ No referral needed ❏ Denied ❏ Approved with modification
NOTES ________________________________________________Signature _____________________________Date: ___/___/_____
Revised