Prior Authorization Request Form Form

Prior Authorization Request Form Please type this document to ensure accuracy and to expedite processing. All fields must be completed for the request to be processed. Please make a selection where applicable throughout the document. DATE TYPE OF REQUEST URGENT STANDARD RETROSPECTIVE TREATMENT SETTING INPATIENT OUTPATIENT REQUEST TYPE EXTENSION INITIAL CANCEL CHANGES DOS/SETTING ADDITIONAL CLINICAL DISCHARGE PLANNING OTHER PREVIOUS AUTHORIZATION NUMBER CONTACT NAME CONTACT PHONE CONTACT FAX MEMBER INFORMATION LAST NAME FIRST NAME MEMBER ID (MEDICAID ID OR HEALTH PLAN ID) MEMBER PHONE NUMBER DATE OF BIRTH MEMBER STREET ADDRESS CITY STATE ZIP Page 1 of 4 ENTOPS2111448791

PROVIDER INFORMATION PROVIDER NAME PROVIDER TIN PROVIDER NPI PROVIDER PHONE NUMBER PROVIDER FAX NUMBER PROVIDER STREET ADDRESS CITY STATE ZIP PROVIDER STATUS PAR NON PAR IN CREDENTIALING FACILITY NAME FACILITY TIN FACILITY NPI FACILITY PHONE NUMBER FACILITY FAX NUMBER FACILITY STREET ADDRESS CITY STATE ZIP PROVIDER STATUS PAR NON PAR IN CREDENTIALING REFERRING PHYSICIAN NAME (IF DIFFERENT FROM ABOVE) REFERRING PHYSICIAN TIN REFERRING PHYSICIAN NPI REFERRING PHYSICIAN PHONE NUMBER REFERRING PHYSICIAN FAX NUMBER REFERRING PHYSICIAN STREET ADDRESS CITY STATE ZIP PROVIDER STATUS PAR NON PAR ____ IN CREDENTIALING Prior Authorization Request Form Page 2 of 4 ENTOPS2111448791

Prior Authorization Request Form Page 3 of 4 ENTOPS2111448791 MEDICAL SECTION DIAGNOSIS CODE
PROCEDURE CODE START DATE END DATE NUMBER OF UNITS CODE DESCRIPTION

Prior Authorization Request Form Page 4 of 4 ENTOPS2111448791 MEDICAL SECTION NOTES PLEASE FAX TO: •
PRIOR AUTHORIZATION FAX: 1-866-497-1384 •
PRIOR AUTHORIZATION RETRO FAX: 1-866-423-1081 •
DME FAX: 1-844-688-2983 •
OB REQUEST FAX: 1-866-497-1384 Providers are responsible for obtaining prior authorization before services are rendered. Service rendered without prior authorization may result in a denial. Please submit clinical information to support medical necessity of the request. Request will not be processed if clinical information or CPT and ICD-10 codes are missing. Authorization is not a guarantee of payment. If you have an urgent request, please call 1-855-396-5770 to initiate the review process. Other Clinical Information Include or attach any clinical and office notes, doctor’s orders, labs, and imaging reports to support medical necessity. If this is an out-of-network request, please provide an explanation and complete the nonparticipating provider form. Important payment notice Please note that reimbursement to any rendering provider for an approved authorization is determined by satisfying the mandatory requirement to have a valid Delaware Medical Assistance (MA) provider ID. However, effective January 1, 2018, any claim submitted by a rendering provider will be denied if it is submitted without the ordering/prescribing/referring provider’s Delaware MA enrolled NPI, or if the NPI does not match that of a Delaware MA enrolled provider. To check the Delaware MA enrollment status of the practitioner that is ordering, referring, or prescribing the service you are providing, visit the Delaware Department of Health and Social Services (DHS) provider look-up portal at: https://medicaid.dhss.delaware.gov/provider.