Pacificare Form PDF Details

The Pacificare Treatment Authorization Form is a critical document within the healthcare system, specifically designed to streamline the process of acquiring necessary medical treatments for patients under specific health plans. It caters to both routine and urgent care needs, with distinct processes tailored for Commercial and Secure Horizons plan types. For routine or standard requests, it specifies the fax numbers for submission, while expedited requests, which are determined by a physician when a standard request poses a serious risk to the patient's health or their ability to regain maximum function, have a dedicated contact number. The form requires detailed information from the ordering provider, including patient details, provider contacts, the nature of the service needed (e.g., inpatient, outpatient, home health), and specific medical details such as clinical history, diagnosis codes, and the treatment plan with CPT codes. It emphasizes checking member eligibility before service provision and clarifies that authorization does not guarantee payment, reflecting the complexity of healthcare coverage. Furthermore, it introduces an alternative, faster authorization method through iExchange Web and outlines the confidentiality and use restrictions associated with the information provided in the form.

QuestionAnswer
Form NamePacificare Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessecurehorizons authorization pdf, securehorizons authorization form, aarp secure horizons authorization pdf, pacificare form

Form Preview Example

TREATMENT AUTHORIZATION FORM

ROUTINE

URGENT* (Commercial only)

PLAN TYPE:

Commercial

 

Secure Horizons

EXPEDITED* (Secure Horizons only)

For Routine/Standard Requests submit via fax to Prior Auth Fax #: Routine (866) 718-6105 Urgent (866) 718-6107

For *Expedited Initial Determination Request call (800) 762-8456, Option 1

*Physician determines that standard request could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.

THIS PORTION TO BE COMPLETED BY ORDERING PROVIDER

 

Patient Name:

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

State:

 

Zip:

 

Home #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex:

M

F

 

DOB:

 

Age:

 

Member ID:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Insurance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ordering

 

 

 

 

 

 

 

 

PCP:

 

Refer to:

 

 

 

Specialty:

 

Provider:

 

 

 

 

 

 

 

 

Specialist:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

State:

 

 

 

Zip:

 

City:

 

 

State:

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office #:

 

 

 

 

Office Fax #:

 

Office #:

 

 

Office Fax #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact:

 

 

 

 

 

 

 

 

 

 

Contact:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Service/Facility:

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Service:

 

Inpatient

Outpatient

Home Health

DME

Non-Contracted/OON Referral

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLINICAL HISTORY & PHYSICAL FINDINGS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIAGNOSIS

 

 

 

 

ICD-9 CM CODES

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EVALUATION & TREATMENT PLAN

 

 

 

 

CPT – 4 CODE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

Code:

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

Code:

 

 

 

 

 

 

Date of Service:

From:

 

 

 

 

 

 

To:

 

 

# Visits/Units Requested:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ordering Provider Signature

 

Date

NOTE: Please check member eligibility prior to providing service. Authorization does not guarantee payment. Benefits and Coverage based on eligibility at the time of service. The member has the right to appeal denial of services through PacifiCare/Secure Horizons

If you are interested in using our real-time authorization & referral system called iExchange Web to process your requests faster & easier, please contact us for more information by calling 1-800-693-8322.

This electronic message transmission contains information from PacifiCare that may be confidential or privileged. The information is intended for the use of the individual or entity named above. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of the information is prohibited. If you have received this electronic transmission in error, please notify us by telephone at the number above or by electronic mail immediately.

How to Edit Pacificare Form Online for Free

Having the purpose of allowing it to be as easy to operate as it can be, we designed this PDF editor. The procedure of filling in the pacificare treatment online can be quick in case you stick to the next steps.

Step 1: Pick the button "Get Form Here".

Step 2: After you've entered the editing page pacificare treatment online, you will be able to notice all of the actions intended for the document within the upper menu.

All of the following sections are what you are going to prepare to obtain the prepared PDF document.

pacificare formulary 2019 empty fields to consider

You should provide the essential details in the Contact, Place of ServiceFacility, Contact, Type of Service, Inpatient, Outpatient, Home Health, DME, NonContractedOON Referral, CLINICAL HISTORY PHYSICAL FINDINGS, DIAGNOSIS, ICD CM CODES, EVALUATION TREATMENT PLAN, CPT CODE, and Code Code area.

Filling in pacificare formulary 2019 stage 2

Be sure to provide the key particulars within the Ordering Provider Signature, Date, NOTE Please check member, If you are interested in using our, and This electronic message box.

Finishing pacificare formulary 2019 step 3

Step 3: If you are done, click the "Done" button to upload your PDF form.

Step 4: It's going to be better to keep duplicates of your document. You can rest easy that we are not going to publish or read your particulars.

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