Wellcare Prior Authorization Form – Fill Out and Use This PDF

The Wellcare Prior Authorization Form is a way for patients to get physician approval prior to receiving services.

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Wellcare Prior Authorization Form PDF Details

If you are like most people, you have never heard of a wellcare prior authorization form. However, if you have ever needed to get prior approval for treatment from your insurance company, then you have filled out this form. The wellcare prior authorization form is a document that you need to fill out in order to get approval from your insurance company for certain treatments or procedures. The form can be used for both medical and dental procedures. If you are planning on undergoing a procedure that requires prior authorization from your insurance company, be sure to download and fill out the wellcare prior authorization form.

You will discover more info about the wellcare prior authorization form by looking through the table we compiled.

Question	Answer
Form Name	Wellcare Prior Authorization Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	47
Avg. time to fill out	9 min 43 sec
Other names	wellcare prior authorization form pdf, medicare determination request form, wellcare prior auth form, wellmed pre authorization form

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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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Make sure you provide the following information to fill out the well, care medicare electronic prior authorization request form PDF:

writing wellcare pa form stage 1

Make sure you submit your data inside the part Treating, Provider, Facility, Fax, No Address, City, State ZIP, Requested, Procedure, Description C, PT, Code Additional, Procedures Primary, Diagnosis Secondary, Diagnosis, es Primary, Diagnosis, Rule, Out Secondary, Diagnosis, es Requested, Procedure, Admit, Date C, PT, Codes Date, of, Last, Office, Visit and ICD, Code

Finishing wellcare pa form part 2

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