Regence Blue Cross Authorization Request PDF Details

The Regence Blue Cross Authorization Request form is a crucial document utilized by healthcare providers to request pre-authorization for a variety of medical services and supplies. This comprehensive form encompasses requests for skilled nursing facilities (SNF), long term acute care (LTAC), inpatient rehabilitation (IP Rehab), behavioral health services, inpatient and outpatient surgeries, outpatient medical services, transplants, durable medical equipment (DME), and professional services. To ensure a smooth process, it urges providers to verify the patient's eligibility and the necessity for pre-authorization before filling out the form. The form is segmented into detailed sections, including patient information, provider information, and the specific preauthorization request, along with instructions on submitting diagnostic, procedural codes, and anticipated service details. It provides different fax numbers and a mailing address for sending completed forms based on the type of service requested. An essential feature of the form is the option for an expedited request, designated for cases where waiting for a standard decision could seriously jeopardize the member's health, highlighting the form's role in facilitating timely access to essential healthcare services.

QuestionAnswer
Form NameRegence Blue Cross Authorization Request
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesregencerx prior request form, blue cross regence idaho medication pa form, regence blue shield of washington prescription drug authorization form, regencerx prior authorization form

Form Preview Example

Pre-Authorization Request Form

Medical Services/Supplies:

 

 Commercial, Individual, Medicare, FEP

Behavioral Health Services: Fax 1 (888) 496-1540

members: Fax 1 (855) 207-1209

SNF, LTAC, IP Rehab: Fax 1 (855) 848-8220

 Administrative Services Only (ASO)

Mail to: PO Box 1271, WW5-53,

members: Fax 1 (844) 679-7763

Portland, OR 97207-1271

Used for skilled nursing (SNF), long term acute care (LTAC), inpatient rehabilitation (IP Rehab), behavioral health services, and medical services including; inpatient and outpatient surgeries, outpatient medical services, transplants, DME and professional services.

Instructions: This form should be filled out by the provider requesting the service or DME. Please complete all applicable fields. Prior to completing this form, please confirm the patient’s benefits, eligibility and if pre-authorization is required for the service.

Have you verified if pre-authorization is required? Yes No

*Note: If no, please verify with the pre-authorization list on the Provider Web site or call the number on the back of the member’s card. Is this request:

New Authorization Extension Providing Additional Information

Medicare Only – Preservice Benefit Organization Determination Request

If you already have an authorization number, please list it here ___________________________________

Expedited request. I attest that this request meets the definition indicated below by checking the expedited request box . Fax to 1 (855) 240-6498.

Expedited is defined as: when the Member or his/her physician believes that waiting for a decision under the standard time frame could place the Member’s life, health, or ability to regain maximum function in serious jeopardy.

SECTION 1 – PATIENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name (Last)

 

 

 

 

 

First

 

 

 

 

 

 

 

MI

Patient’s Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient’s Regence Member ID Number

Group Number

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 2 – PROVIDER INFORMATION

 

 

 

 

 

 

 

 

 

 

Please check one: Requesting Provider

Rendering Provider DME Supplier

Provider Name

 

 

 

 

 

 

 

 

 

 

 

Tax ID Number

 

 

 

 

 

 

 

 

 

NPI

 

 

Phone Number

 

 

Confidential

Voice Mail

Fax Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

Provider Address

 

 

 

 

 

 

 

City

 

 

 

 

 

State Zip Code

Who should we contact if we require additional information?

Name

Phone Number

Ext.

Confidential Voice Mail

Yes No

Fax Number

FORM 5266WA - Page 1 of 2 (Eff. 6/18) v1

SECTION 3 – PREAUTHORIZATION REQUEST

Is this request: Pre-Service or Concurrent Review

 

Date of Service (if scheduled) __________________ (mm/dd/yyyy)

 

 

Please check one: Outpatient Hospital

 

Inpatient

ASC

Office

 

 

 

 

 

Other____________________________________

 

 

 

 

Please check all that apply: Surgical

DME Diagnostic

Medical

 

 

 

 

Other____________________________________

 

 

 

 

 

 

 

 

 

 

 

 

Rendering or Treating Provider and Provider Specialty

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Address where services will occur

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

IF INPATIENT OR OUTPATIENT FACILITY

 

 

IF

DME

 

 

Facility Name

 

 

 

Company Name

 

 

 

 

 

 

 

 

 

 

 

 

 

Anticipated Admission

Anticipated Length of stay

Tax ID Number

 

NPI

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

Note: If anticipated length of stay is not indicated, no

DME Address

 

 

 

 

more than two days will be assigned if approved.

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

Zip Code

Note: This form does not serve as a notification of

 

 

 

 

 

 

Signed copy of prescription attached: Yes No

admission. Please reference the Provider Web site for

instructions to notify us of an admission.

 

 

Invoice attached: Yes No

 

 

Please provide all diagnosis, CPT® or HCPCS codes

and their descriptions, if available; this will help

processing of your request.

 

 

 

 

 

 

 

 

Diagnosis code(s) and description(s)

 

CPT® or HCPCS code(s) and description(s)

DME Only Line

 

 

 

 

 

 

 

 

 

Item Cost

Primary:

 

 

 

 

 

 

 

$

Second:

 

 

 

 

 

 

 

$

Third:

 

 

 

 

 

 

 

$

Please submit the following clinical documentation with this form as appropriate for this request:

History & Physical Lab/Radiology/Testing Results Current Symptoms & Functional Impairments

Treatment History and any other information such as chart notes that support medical necessity for the request.

FORM 5266WA - Page 2 of 2 (Eff. 6/18) v1

How to Edit Regence Blue Cross Authorization Request Online for Free

It shouldn’t be difficult to obtain regence prior authorization form applying our PDF editor. This is the way you will be able conveniently develop your document.

Step 1: You can hit the orange "Get Form Now" button at the top of this webpage.

Step 2: After you've entered the editing page regence prior authorization form, you'll be able to notice all of the options readily available for your file inside the top menu.

Complete the regence prior authorization form PDF and provide the material for each section:

example of fields in regence blue shield of washington prescription drug authorization form

Fill in the SECTION PROVIDER INFORMATION, Tax ID Number, NPI, Phone Number, Provider Address, Confidential Voice Mail Yes No, Fax Number, City, State Zip Code, Who should we contact if we, Phone Number, FORM WA Page of Eff v, Ext, Confidential Voice Mail Yes No, and Fax Number areas with any data that can be asked by the software.

part 2 to entering details in regence blue shield of washington prescription drug authorization form

In the SECTION PREAUTHORIZATION REQUEST, Date of Service if scheduled, Please check one Outpatient, Other, Please check all that apply, Other, Rendering or Treating Provider and, Physical Address where services, City, State Zip Code, IF INPATIENT OR OUTPATIENT FACILITY, IF DME, Facility Name, Anticipated Admission mmddyyyy, and Company Name part, emphasize the necessary particulars.

part 3 to completing regence blue shield of washington prescription drug authorization form

The space Note This form does not serve as a, Signed copy of prescription, Diagnosis codes and descriptions, Primary Second Third, CPT or HCPCS codes and, Item Cost, Please submit the following, History Physical Current, LabRadiologyTesting Results, and request should be where you can indicate all parties' rights and responsibilities.

regence blue shield of washington prescription drug authorization form Note This form does not serve as a, Signed copy of prescription, Diagnosis codes and descriptions, Primary Second Third, CPT or HCPCS codes and, Item Cost, Please submit the following, History Physical Current, LabRadiologyTesting Results, and request blanks to insert

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