Humana Pain Management Authorization Form PDF Details

Navigating the complexities of healthcare requirements can be daunting, especially when it involves procedures as critical as spinal surgery or pain management. In such instances, the Humana Pain Management Authorization form serves as a vital link between healthcare providers and insurance coverage, ensuring that necessary treatments are approved and processed efficiently for Humana members. This document is designed to streamline the prior authorization process for specific procedures, including but not limited to spinal surgery, epidural steroid injections, spinal decompression, and implantable pain pumps. The form mandates detailed information about the provider, patient, and requested services, emphasizing the importance of accuracy and completeness. Providers are instructed to submit this form, along with all relevant clinical documentation, to OrthoNet, reflecting a structured approach to securing authorization. Additionally, guidance is offered for filling out the form correctly, and contact information for OrthoNet is provided, should questions or uncertainties arise. This process underscores the collaborative effort between healthcare providers, insurance facilitators, and patients in making pain management and spinal surgery services accessible, all while maintaining the confidentiality of the transmitted information.

QuestionAnswer
Form NameHumana Pain Management Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshumana orthonet spine surgery form, humana spinal surgery orthonet form, orthonet humana pain management prior authorization form, humana orthonet pain management form

Form Preview Example

 

 

 

 

 

 

 

HUMANA Pain Management & Spinal Surgery

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prior Authorization Request Form

 

 

 

 

 

 

 

47926

 

 

 

 

 

 

 

Instructions: 1. Use this form when requesting prior authorization of spinal surgery or pain management procedures for Humana members.

2.Please complete and Fax this request form along with all supporting clinical documentation to OrthoNet at 1-888-605-5345. (This completed form should be page 1 of the Fax.)

3.For assistance in completing this form or if you should have any question about whether or not the procedure requires prior authorization, please contact OrthoNet toll free at 1-888-605-5344 for Pain Management and at 1-866-565-4733 for Spinal Surgery procedures.

4.Please PRINT, in black ink, one character per box for ALL requested information and completely fill in each circle for selection where applicable.

NOTE: The information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL material. If you receive this material/information in error, please contact the sender and delete or destroy the material/information.

 

PROV I D ER I N FORM ATI ON :

 

 

Fa x D a t e :

 

 

 

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N u m be r of pa ge s fa x e d :

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

( in clu din g t h is cov er p a ge )

 

 

 

Pr ov id e r N a m e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

St r e e t Ad dr e ss

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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St a t e

 

ZI P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Te le p h o n e N u m be r

 

 

 

 

 

 

N a t ion a l Pr ov id e r I d e n t if ie r ( N PI )

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Facility NPI Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual NPI Number

 

 

 

 

 

 

 

 

 

 

Fa x N u m be r

 

 

 

 

 

 

 

 

 

Pr ov id e r Ta x I D N u m be r

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

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Facility Tax ID Number

Individual Tax ID Number

PATI EN T I N FORM ATI ON :

Fir st N a m e

La st N a m e

D a t e of Bir t h

/

M on t h D a y

H U M AN A M e m be r I D N u m be r

 

D ia g n osis Cod e ( I CD - 1 0 For m a t )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

Ye a r

REQU EST I N FORM ATI ON :

Re q u e st f or : ( Ch eck al l t h at m ay app ly )

Fa ce t Join t I n j e ct ion

Epidu r a l St e r oid I n j e ct ion ( Spin a l)

I m pla n t a ble Pa in Pu m p

Spin a l St im u la t or

Spin a l D e com pr e ssion

Spin a l Fu sion

V e r t e br opla st y / Ky ph opla st y

Sp in a l Re g ion ( s) :

Ce r v ica l

T h o r a cic

Lu m b a r

Sa cr a l

Ye s

N o

N / A

H a s t h e pa t ie n t h a d pr ior spin a l su r ge r y ?

I s t h is t h e fir st e pidu r a l st e r oid or fa ce t

Ye s

N o

N / A

inj e ct ion fo r t his pa t ie n t ?

 

 

 

I s t h e M R/ CT r e por t a t t a ch e d t o t h is

Ye s

N o

N / A

r e qu e st ?

 

 

 

CPT Code ( s) :

An t icipa t e d D a t e of Se r vice ( s)

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/

Re q u e st e d Fa cilit y f or Su r g e r y / Pr oce d u r e ( s) ( I f Ap p lica b le )

M on t h D a y

Ye a r

Ci t y

St a t e

 

 

Te le p h o n e N u m be r

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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47926

Copyright 2011 OrthoNet, LLC

Rev. 1/1/2011

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