Prior Auth Required

01176 - confidentiality statement as a cover sheet to all faxed PA requests. The Prior Authorization Fax Cover Sheet (F- (12/11))

This procedure appears on the selected insurer prior authorization source.

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Prior authorizationPrior Auth Required
Procedure / Serviceconfidentiality statement as a cover sheet to all faxed PA requests. The Prior Authorization Fax Cover Sheet (F- (12/11))
Procedure / Service Description

To help safeguard the confidentiality of member health care records, providers should include a fax transmittal form containing a - To help safeguard the confidentiality of member health care records, providers should include a fax transmittal form containing a confidentiality statement as a cover sheet to all faxed PA requests. The Prior Authorization Fax Cover Sheet (F-01176 (12/11))

Likely documents
  • Confirm benefit details
  • Submit clinical notes if requested by the plan
Next actions
  • Confirm the current plan policy before submission.
  • Use the insurer authorization workflow for this listed code.