Sunshine Health Id Printout Form PDF Details

Managing healthcare services requires careful coordination and adherence to specific protocols to ensure that patients receive the timely care they need. The Sunshine Health ID Printout form is a critical element in this process, particularly for outpatient services that demand prior authorization. This form serves as a standard request for authorization that might take up to 14 days to process, signaling the importance of its meticulous completion and timely submission via fax. The form requests detailed information, including member and provider specifics, to facilitate an efficient authorization process. It explicitly mandates the inclusion of member ID/Medicaid ID, date of birth, requesting provider information, and details about the servicing provider or facility. Moreover, the form delineates the need for specifying the authorization request particulars like the primary and additional procedure codes, service type, and the expected duration of the treatment or service. The facility for marking urgent requests is provided, emphasizing the form's role in accommodating immediate healthcare needs. Additionally, it underscores the importance of completing all required fields and attaching relevant clinical information to avoid delays or rejection, reminding the submitter that an authorization does not guarantee payment. The statement regarding patient eligibility, coverage, and medical necessity encapsulates the intricacies of health plan policies. The form concludes with a stern confidentiality notice in compliance with the Health Insurance Portability and Accountability Act of 1996, highlighting the sensitivity and privacy of the information shared within.

QuestionAnswer
Form NameSunshine Health Id Printout Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessunshine pa form, bs of ca promise health plan pa form, sunshine prior authorization form, sunshine health pa form

Form Preview Example

OUTPATIENT

Complete and Fax to: 1-866-796-0526

Prior Authorization Fax Form

This is a standard authorization request that may take up to 14 days to process. If this is an urgent/stat request, please contact us at 1-866-796-0530.

Request for additional units. Existing Authorization

Units

*INDICATES REQUIRED FIELD

 

 

 

 

 

Date of Birth *

MEMBER INFORMATION

 

 

 

Member ID/Medicaid ID *

 

(MMDDYYYY)

 

Last Name, First

REQUESTING PROVIDER INFORMATION

 

Requesting NPI *

Requesting TIN *

Requesting Provider Contact Name

*0322*

Requesting Provider Name

Phone

Fax

SERVICING PROVIDER / FACILITY INFORMATION

Same as Requesting Provider

Servicing NPI *

 

Servicing TIN*

 

Servicing Provider Contact Name

Servicing Provider/Facility Name

Phone

 

Fax

 

 

 

AUTHORIZATION REQUEST

 

 

 

 

Primary Procedure Code *

Start Date OR Admission Date

*

Diagnosis Code

*

(CPT/HCPCS)

(Modiier)

(MMDDYYYY)

 

(ICD-9)

 

Additional Procedure Code

End Date OR Discharge Date

 

Total Units/Visits/Days

(CPT/HCPCS)

(Modiier)

(MMDDYYYY)

 

 

 

OUTPATIENT SERVICE TYPE *

(Fill in the square with an X)

Auditory Services

Hospital Outpatient Surgery

 

Office Visit

Observation

 

Other Site

OB Ultrasound

Dialysis (Non Par Only)

Office Visit

 

Genetic Testing

Other Site

 

Global OB Care

Oice Visit (non-participating)

Office Visit

Office Visit

 

Other Visit

Other Site

Orthotics and Prosthetics

Transplants (Evals and Consults)

(If purchase price greater

 

than $500)

Office Visit

Pain Management

Other Visit

 

Office Visit

 

 

Transportation

Other Site

(Non-emergency)

 

Rehab (OT/PT/ST)

Please contact NIA for Radiology Services. Please contact Univita for DME and Home Health Care services.

ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.

COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.

Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Beneit and medically necessary with prior authorization as per Plan policy and procedures.

Confidentiality: The information contained in this transmission is conidential and may be protected under the Health Insurance Portability and Accountability Act of 1996.

 

If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and

FL-PAF-0322

destroy this document.

How to Edit Sunshine Health Id Printout Form Online for Free

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As a way to finalize this document, be sure to type in the information you need in every area:

1. Before anything else, when filling out the sunshine health pa form, start out with the form section that has the following fields:

Filling out part 1 of sunshine state helath plan medicaid prior authorization form

2. After the last segment is done, you're ready to include the required particulars in Servicing NPI, Servicing TIN, Servicing Provider Contact Name, Servicing ProviderFacility Name, Phone, Fax, AUTHORIZATION REQUEST, Primary Procedure Code, Start Date OR Admission Date, Diagnosis Code, CPTHCPCS, Modiier, MMDDYYYY, ICD, and Additional Procedure Code so you're able to proceed further.

Find out how to prepare sunshine state helath plan medicaid prior authorization form portion 2

3. This next step is going to be hassle-free - complete every one of the fields in ALL REQUIRED FIELDS MUST BE FILLED, COPIES OF ALL SUPPORTING CLINICAL, Disclaimer An authorization is not, FLPAF, Please contact NIA for Radiology, Global OB Care, Office Visit, Other Visit, Oice Visit nonparticipating, Office Visit, Other Site, and Rehab OTPTST to conclude this segment.

Part # 3 for submitting sunshine state helath plan medicaid prior authorization form

People who use this document often make some errors when filling out Disclaimer An authorization is not in this part. Make sure you review whatever you enter here.

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