Regence Blue Cross Authorization Request PDF Details

Are you looking for a Regence Blue Cross authorization request form? You've come to the right place. In this blog post, we will provide you with all the information you need to know about the authorization request process. We will also provide you with a link to download the authorization request form.

You will see details about the type of form you wish to fill out in the table. It will show you how long it may need to fill out regence blue cross authorization request, exactly what parts you will have to fill in and some additional specific facts.

QuestionAnswer
Form NameRegence Blue Cross Authorization Request
Form Length2 pages
Fillable?Yes
Fillable fields4
Avg. time to fill out1 min 22 sec
Other namesregence blue shield of washington, regence bcbs prior authorization, blue cross regence idaho medication pa form, regencerx prior request 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 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, you'll be able to notice all of the options readily available for your file inside the top menu.

Complete the re, gence prior authorization PDF and provide the material for each section:

example of fields in blue cross regence idaho medication pa form

Fill in the TaxI, D, Number NP, I Provider, Address Phone, Number Confidential, Voice, Mail, Yes, No Fax, Number City, State, Zip, Code Phone, Number Ext, Confidential, Voice, Mail, Yes, No Fax, Number and FOR, MW, A, Page, of, Eff, v areas with any data that can be asked by the software.

part 2 to entering details in blue cross regence idaho medication pa form

In the Date, of, Service, if, scheduled, mm, dd, yyyy Other, Other, City, State, Zip, Code IF, INPATIENT, OR, OUTPATIENT, FACILITY Facility, Name Company, Name Anticipated, Length, of, stay, TaxI, D, Number IF, D, ME NP, I D, ME, Address City, and State, Zip, Code part, emphasize the necessary particulars.

part 3 to completing blue cross regence idaho medication pa form

The space Item, Cost Lab, Radiology, Testing, Results and request should be where you can indicate all parties, ' rights and responsibilities.

blue cross regence idaho medication pa form ItemCost, LabRadiologyTestingResults, and request blanks to insert

Step 3: Select the "Done" button. Now you can export your PDF form to your gadget. In addition, you can easily send it by means of email.

Step 4: Generate copies of the document. This can protect you from possible difficulties. We cannot look at or distribute your data, so be sure it will be protected.

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