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.

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

 

How to Edit Wellcare Prior Authorization Form Online for Free

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

Step 3: Hit the "Done" button. So now, it is possible to transfer your PDF file - download it to your electronic device or deliver it by means of electronic mail.

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

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