Scan Prior Authorization Form PDF Details

Understanding the nuances of healthcare paperwork can often feel like navigating a labyrinth. Among the myriad forms that both patients and healthcare providers must familiarize themselves with is the Scan Prior Authorization request form. This form plays a pivotal role in the healthcare process, acting as a prerequisite for certain medical services or medications. The form requires detailed information, including the member’s personal details, the requesting physician's information, and specifics about the requested service, including diagnosis codes and the type of service needed. A fundamental aspect of this form is the classification of the request based on urgency, distinguishing between standard, urgent, and expedited/STAT requests. This classification underscores the importance of timely medical intervention and the potential impact on a patient’s health and well-being. The form also facilitates the communication process between healthcare providers and insurance companies, ensuring that the necessary services are approved and can proceed without undue delay. It embodies the intricate dance between ensuring patient care is both timely and within the bounds of insurance stipulations, a critical pathway to ensuring healthcare access and affordability.

QuestionAnswer
Form NameScan Prior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesscan authorization, scan insurance auhorization form, scan health prior, scan health prior authorization form

Form Preview Example

Prior Authorization Request Form

Fax: (602) 778-3331

(Excluding DME/Medical Supplies)

Phone: (602) 778-3330

 

 

 

1-866-406-0955

Date of Request: ____________________

 

 

Standard/Routine (up to 14 calendar days)

Urgent (ASAP not to exceed 14 calendar days)

Expedited/STAT (up to 3 business days) Use only when following the standard time frame could seriously jeopardize the member’s life of health or ability to attain, maintain, or regain maximum function.

Member Information

 

Member Name:

 

 

 

Address:

 

 

 

 

 

Phone Number:

 

 

City:

 

State:

 

Zip:

 

 

Patient ID Number:

 

 

 

DOB:

/

/

Age:

 

 

Medicare

฀ Yes

฀ No

Other Insurance:

 

 

 

 

 

 

 

 

 

 

Requesting Physician Information

 

 

 

 

 

 

 

 

 

 

 

Requesting Physician:

 

Name of Person Completing Form:

 

 

 

Phone Number:

 

 

RETURN AUTHORIZATION TO THIS FAX #:

 

 

Diagnosis: _______________________

ICD-9: ____________ CPT Code(s): ____________

HCPC Code(s): ____________

 

 

 

_______________________

 

____________

____________

 

____________

 

 

 

_______________________

 

____________

____________

 

____________

 

 

 

_______________________

 

____________

____________

 

____________

 

 

 

 

 

 

Authorization Request

 

 

 

 

 

Referring To:

 

 

Frequency:

 

 

Duration:

 

 

 

Address:

 

 

 

Phone Number:

 

 

 

 

 

 

Facility/Hospital Name:

 

 

 

 

 

 

 

 

Address:

 

 

 

Expected Date of Service:

 

 

 

 

฀ Office

฀

Inpatient Services

฀ Outpatient Services

฀

23 Hour Short Stay/Observation

 

Describe symptoms, duration, tried and/or failed treatment, relevant lab, diagnostic test (if possible please fax in supporting documentation with request):

HEALTH PLAN USE ONLY

Approved

Authorization Number: _____________________________________ Valid From: __________ to __________ Expiration Date

Denied Denial Reason:

_____________________________________

_____________________________________

____________________

Medical Director Signature

PA Nurse/Tech Signature

Date

Authorization is subject to eligibility on date of service. To ensure proper payment for services rendered, please verify eligibility on date of service. If the member is determined to be ineligible on date of service, he/she may be responsible for payment of these services.

Availability/Accessibility Standards apply to Contracted and Non Contracted Providers

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How to complete scan health plan prior authorization step 1

2. The subsequent part is to fill out these blank fields: Address, Phone Number, FacilityHospital Name, Address Office Inpatient Services, Expected Date of Service, Outpatient Services, Hour Short StayObservation, Describe symptoms duration tried, HEALTH PLAN USE ONLY, Approved Authorization Number, Medical Director Signature, Authorization is subject to, PA NurseTech Signature, and Date.

Stage # 2 for filling out scan health plan prior authorization

Many people generally make some errors when filling in Describe symptoms duration tried in this area. You should review whatever you type in right here.

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