Pacificare Prior Authorization Form Details

Pacificare Health Systems is a company that offers health insurance and other health benefits to individuals, families, and businesses. The company has several different plans available, and it can be difficult to determine which plan is best for you or your organization. Pacificare Form is an online tool that can help you make this decision. With Pacificare Form, you can compare the features of different plans, find out if you are eligible for discounts, and even apply for coverage. This tool makes it easy to find the right plan for your needs.

In the listing, there's some good information about the pacificare form. You will have the estimated time it'd require you to complete the form plus some further details.

QuestionAnswer
Form NamePacificare Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesaarp secure horizons authorization pdf, pacificare prior authorization form, uhc pacificare secure horizon preauthorization request form, securehorizons authorization form

Form Preview Example

®

ROUTINE

URGENT

STAT

 

 

 

 

TREATMENT AUTHORIZATION FORM

From:

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

Prior Auth. Fax #

 

(800) 457-3828

PLAN TYPE:

Commercial

 

 

 

 

 

City, State, Zip:

 

 

Home Health Auth. Fax #

(800) 207-1833

 

Secure Horizons

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DME Auth. Fax #

 

(800) 710-8812

 

 

Fax Back No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS PORTION TO BE COMPLETED BY PHYSICIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name:

 

 

 

Primary Care MD:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

Refer To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

State:

Specialty:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip:

 

Home #:

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex:

 

DOB:

 

Age:

City:

 

State:

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

Member ID#:

 

 

 

Office #:

 

 

Office Fax #:

 

 

 

 

 

 

 

 

 

 

 

 

Type of Service: Inpatient

Outpatient

Home Health DME Initial Visit

CLINICAL HISTORY & PHYSICAL FINDINGS

Return Visit

Other

REASON FOR REFERRAL: Consultation

Testing

Follow-up

Procedure

No. of Visits Requested:

 

 

 

 

 

 

 

 

 

DIAGNOSIS

 

 

 

ICD-9 CM CODE:

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

EVALUATION & TREATMENT PLAN

 

 

RVS/CPT – 4 CODE:

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUESTED FACILITY

Accident: Yes

No

Occurrence: Home

Work

Auto

Other

Other Insurance: _____________________________________________________________________________

MD Signature: ___________________________________________ Date: ____________________________

*** NOTE: The member has the right to appeal denial of services through PacifiCare/Secure Horizons

THIS PORTION TO BE COMPLETED BY UR ONLY. THIS REFERRAL FORM DOES NOT GUARANTEE ELIGIBILITY.

PLEASE CHECK ELIGIBILITY PRIOR TO PROVIDING SERVICE.

Authorization #:

Date: ________/__________/_________

Provider Contracted

Yes

No

Assigned Length of Stay: ______________________________

Facility Contracted

Yes

No

 

 

 

________

Authorized

Date _____________

Initials _______

CPT Codes Authorized/No. of Visits _________________________

________

Pended

 

Date _____________

Initials _______

Reason _______________________________________________

________

Denied

 

Date _____________

Initials _______

Reason _______________________________________________

________

Modified

Date _____________

Initials _______

Reason _______________________________________________

 

 

 

 

 

 

SE 7-26-00