Wellcare Prior Authorization Form PDF Details

Navigating the healthcare system can be complex, especially when it comes to ensuring that certain medical services and prescriptions are covered by a patient's insurance plan. The Wellcare Prior Authorization form serves as a crucial tool in this process, designed to secure approval from Wellcare before certain procedures, medications, or services are provided to the patient. This form requires detailed information, including the patient's name, date of birth, member ID, and contact details, alongside specifics about the requested healthcare service such as type of referral, procedure descriptions, diagnosis codes, and the treating provider’s details. It distinguishes between different types of services like inpatient admissions, outpatient surgery, and diagnostic testing, each with distinct fax numbers for submission based on the care setting—national or TexanPlus. Important to note is the provision for expedited requests, catering to situations where waiting for the standard determination could significantly jeopardize the patient’s health. This form underscores the importance of coordination between healthcare providers and Wellcare, ensuring that all necessary clinical documentation accompanies the request to facilitate the decision-making process. It also highlights the privacy considerations inherent in transmitting sensitive patient information, emphasizing the confidentiality and proper handling of the submitted data. For healthcare providers and members of the Wellcare plan, understanding and accurately completing this form is pivotal to streamlining the authorization process and ensuring timely access to required medical services.

QuestionAnswer
Form NameWellcare Prior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswellcare medicare prior authorization form, medicare determination request form, wellcare prior auth form, wellcare medicare electronic prior authorization request form

Form Preview Example

National, Fax to:

Inpatient: 1-855-776-9464

Outpatient: 1-877-892-8215

TexanPlus, Fax to:

Inpatient: 1-713-621-8441

Outpatient: 1-713-965-9440

Authorization Request Form

Date: ______________________________________

This request will be treated as per the standard organization determination time frames. If the request needs to be treated as expedited, please provide justification that applying the standard time for making a determination could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function:

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Patient Name:

DOB:

 

 

 

 

 

 

Member ID No.:

 

Member Phone No.:

 

 

 

 

 

Member Address:

City:

State:

ZIP:

 

 

 

 

Referral Type:

 

 

 

Inpatient Admit Office Visit

Outpatient Surgery Observation

Home Health (SN/ST/PT/OT) Other

DME

OP Therapy (ST/PT/OT)

Diagnostic Procedure/Testing:

Requesting Physician:

WellCare Provider ID No.:

 

 

 

 

 

 

 

 

Address:

City:

 

State:

 

ZIP:

 

 

 

 

 

 

Phone No.:

Fax No.:

 

 

 

 

 

 

 

 

 

 

Contact Person:

 

 

 

 

 

 

 

 

 

Treating Provider/Facility:

WellCare Provider ID No.:

Phone No.:

 

 

 

 

 

 

Fax No.:

Address:

 

City/State:

 

ZIP:

 

 

 

 

 

 

If Referring Out-of-Network, Please State Reason:

 

 

 

 

 

 

 

 

 

 

 

Requested Procedure Description:

 

 

 

 

 

 

 

 

CPT Code:

 

Requested Procedure/Admit Date:

 

 

 

 

 

Additional Procedure(s):

 

CPT Code(s):

 

 

 

 

 

 

 

Primary Diagnosis

 

Date of Last Office Visit:

 

 

 

 

 

 

 

 

Secondary Diagnosis(es):

 

 

 

 

 

 

 

 

 

 

Primary Diagnosis/Rule Out:

 

ICD – 10 Code:

 

 

 

 

 

 

 

Secondary Diagnosis(es):

 

ICD – 10 Code(s):

 

 

**PLEASE INCLUDE CLINICAL DOCUMENTATION WITH REQUEST**

ALL REFERRALS FOR HMO PLAN MEMBERS MUST BE MADE TO CONTRACTED PROVIDERS

ALL LABWORK MUST BE SENT TO: Quest Diagnostics or other in-network lab provider.

Privacy Notification: This facsimile and any accompanying documents may contain confidential and/or proprietary information, which should not be viewed or used by anyone other than the individual to whom the fax is sent and other authorized individuals as appropriate. The reader is hereby notified that any unauthorized copying, dissemination, or distribution of this fax is prohibited. If you have received this fax by mistake, please telephone (collect if necessary) the sender and notify the person that you have received the fax by mistake and that the document has been destroyed.

PRO_28672E Internal Approved 12282018

NA9UAMFRM28672E_0000

©WellCare 2019

 

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Our PDF editor allows you to complete the wellcare prior authorization form michigan form. It will be easy to generate the file immediately through using these simple actions.

Step 1: Click on the button "Get Form Here".

Step 2: So, you can start editing your wellcare prior authorization form michigan. The multifunctional toolbar is available to you - add, delete, alter, highlight, and conduct similar commands with the words and phrases in the document.

Make sure you provide the following information to fill out the wellcare prior authorization form michigan PDF:

writing wellcare michigan prior authorization form stage 1

Make sure you submit your data inside the part Treating ProviderFacility Fax No, WellCare Provider ID No Address, Phone No, CityState, ZIP, Requested Procedure Description, Primary Diagnosis Secondary, Primary DiagnosisRule Out, Requested ProcedureAdmit Date CPT, Date of Last Office Visit, ICD Code ICD Codes, PLEASE INCLUDE CLINICAL, Privacy Notification This, and NAUAMFRME.

Finishing wellcare michigan prior authorization form part 2

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Step 4: You will need to generate as many duplicates of your form as you can to prevent future misunderstandings.

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