Prior Authorization Form PDF Details

At the heart of ensuring that patients receive the necessary medical care while navigating the complexities of health insurance coverage lies the Prior Authorization form, a critical document used across the healthcare industry. Emblematic of the intricate dance between healthcare providers, insurance companies, and patients, the form serves multiple pivotal roles. It acts as a referral mechanism, signaling to specialists that a primary care physician deems a consultation or treatment necessary. Furthermore, it underscores the importance of network adherence, particularly for patients under specific health plans, such as those affiliated with Banner Health Network, by stipulating that care should be sought from contracted providers to leverage benefits effectively. Besides facilitating the referral process, the Prior Authorization form plays a crucial role in the administrative side of healthcare, ensuring that all procedural and diagnostic services are pre-approved to avoid unwelcome financial surprises for patients. This process involves detailing the planned date of service, patient information, details of the requested provider including their Tax Identification Number (TIN), and the specifics of the treatment or consultation needed, along with relevant codes such as the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT). It also highlights the importance of complete and accurately filled forms, warning that any omission could lead to processing delays or outright refusal to see the patient, emphasizing the form's role in streamlining patient care coordination while adhering to policy requirements.

QuestionAnswer
Form NamePrior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesbanner university family care prior auth form, university family care prior authorization form, university family care prior auth form, banner university family care prior auth

Form Preview Example

BANNER HEALTH NETWORK

REFERRAL/PRIOR AUTHORIZATION FORM

ATTENTION PATIENTS:

THIS IS YOUR REFERRAL FORM. THE SPECIALIST MAY REFUSE TO SEE YOU WITHOUT IT.

Incomplete forms will not be processed and will be returned to sending provider.

Planned Date of Service: ___________________ (Recommend not scheduling until authorization is obtained)

Patient: ____________________________________________________ DOB:____________________________

Patient’s Health Plan: __________________________________________ ID# ____________________________

Requested Provider: ____________________________________________TIN#___________________________

(Full Name)

Specialty:___________________________________________ Out of Network____ Inpt ___Outpt____Office___

Office Contact Name: _____________________________Phone# ________________ Fax# _________________

(Requested Provider Office)

Place of Service:_______________________________________________TIN#____________________________

(Facility Name)

Referring Provider: ______________________________ Phone# _________________ Fax# _________________

(Full Name)

Office Contact Name: _____________________________Phone# ________________ Fax# _________________

(Referring Provider Office)

Requested Action by Specialist (Optional for PCP to Complete):

Consultation: (Please send the patient back for follow-up and treatment)

[ ] Confirm Diagnosis [ ] Advise as to Diagnosis [ ] Suggest Medication or Treatment

Referral: (Please provide PCP with summaries of subsequent visits)

[] Assume management for this particular problem and return patient after conclusion of care. [ ] Assume future management of patient within your area of expertise.

Diagnosis/ICD-9: _______________________________________________________________________________

Treatment/Procedure with CPT/HCPCS codes:_______________________________________________________

Submit Information for request: List units being administered, Notes, labs, x-rays

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Provider Signature

Date

THE FOLLOWING APPLIES ONLY TO “Banner Choice Plus” PATIENTS:

To access your Banner Option Benefit, your Primary Care Physician should refer you to a contracted provider.

To ensure recommended provider is contracted, call Banner Benefits Service Center at 480-684-7070 (within Metro Phoenix area) or at 800-827-2464 or go on the web www.BannerHealthPlans.com

For Banner Use Only:

BHN Prior Authorization Dept Phone: 480-684-7070 Fax: 480-684-7200 (within Metro Phoenix Area) or 800-697-1441

The information contained in this facsimile message is confidential and intended only for the use of the individual(s) named above. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by telephone and destroy facsimile. Thank you

BHN Referral Form Revised on 7-6-12

How to Edit Prior Authorization Form Online for Free

banner health authorization form can be completed in no time. Simply try FormsPal PDF tool to complete the job promptly. FormsPal professional team is relentlessly working to enhance the editor and ensure it is much better for users with its multiple functions. Uncover an constantly progressive experience now - check out and uncover new opportunities along the way! Getting underway is simple! All you should do is take these basic steps down below:

Step 1: Open the PDF file inside our editor by clicking on the "Get Form Button" at the top of this webpage.

Step 2: With the help of this handy PDF editor, it is easy to do more than just fill in blank form fields. Edit away and make your docs look faultless with custom text incorporated, or adjust the original content to excellence - all that backed up by an ability to insert stunning images and sign the file off.

With regards to the blanks of this particular document, here's what you need to do:

1. While completing the banner health authorization form, make certain to complete all important blank fields in their corresponding area. This will help to expedite the work, allowing your information to be processed swiftly and accurately.

Part no. 1 for submitting banner health network uhc pre authorization form

2. After this segment is finished, it's time to put in the needed particulars in DiagnosisICD TreatmentProcedure, THE FOLLOWING APPLIES ONLY TO, To access your Banner Option, and For Banner Use Only allowing you to move forward further.

Completing segment 2 of banner health network uhc pre authorization form

It is possible to get it wrong while filling in the THE FOLLOWING APPLIES ONLY TO, therefore ensure that you reread it prior to when you finalize the form.

Step 3: Just after proofreading the fields you've filled in, click "Done" and you are done and dusted! Acquire your banner health authorization form the instant you subscribe to a free trial. Readily view the pdf form within your FormsPal account, with any edits and changes all synced! At FormsPal.com, we do our utmost to make sure that all of your information is maintained protected.

Prior Authorization Form isn’t the one you’re looking for?

Related Documents