Prior Authorization Request Form PriorAuth.Allplan_Form 01/01/2023

Fax #: 808.973.0676 (Oahu)

888.667.0680 (NI) Phone #: 808.973.0712

Website: www.alohacare.org Fax #: 808.944.5611 Phone #:

808.948.6464 (Oahu)

800.344.6122 (NI) 800.877.5394 (Mainland) Website: hhin.hmsa.com Fax #: 888.881.8225 Phone # for Expedited:

888.505.1201 (Medicare) 888.846.4262 (Medicaid) Website: provider.wellcare.com Fax #: 800.267.8328 Phone #: 888.980.8728 Website:

Healthcare Provider Resources- UHCprovider.com  Standard request For Medicare and Medicaid plans: decision & notification are made within 14 calendar days For HMSA Commercial, Federal and EUTF plans: decisions & notification are made within 15 calendar days  Expedited request (MD, PA, RN, RD or LPN) Signature required) Decision & notification are made within 72 hours* or as expeditiously as this member’s health condition requires if urgent criteria are met.

By signing below, I certify that following the standard timeframe could seriously jeopardize this member’s life or health or ability to attain, maintain, or regain maximum function. Signature (if left blank, request will be reviewed based on standard timeframes) Date signed  Retrospective Retrospective authorization is defined as a request for services that have been rendered but a claim has not been submitted. *From receipt of request, provided that all relevant supporting clinical information and documentation are submitted.

To avoid delays, please attach supporting documents

A. Member information

Membership ID

Patient’s Name (Last, First MI)

Date of birth (MM/DD/YYYY) Member’s Physical Address

Phone # B. ICD-10-CM diagnosis code(s) Diagnosis code(s):

Place of service: Inpatient Outpatient/ASC (ambulatory surgical center) Labs and diagnostic (outpatient) Office Home For Rehab Services (check one): PT OT Speech Initial Continuing Last Date of Service: ___ Total Visits Used:____

CPT/HCPCS code(s) Cost of DME Modifier

of units

CPT/HCPCS code(s) Cost of DME Modifier

of units

Service date(s):

  to

Hospital Discharge

D. Provider information

Requesting (or referring) provider name

Provider ID/NPI/TIN Address

Contact Name

Phone No.

Fax No. Servicing Provider/Facility/Vendor (if different from requesting or referring provider)

Provider ID/NPI/TIN Address

Contact Name

Phone No.

Fax No. E. General Comments

C. Procedure/service/treatment information I SIGN