EmblemHealthCommercial Clinical Policy

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Indications

(1) Please complete and Fax this request form along with all supporting clinical documentation to OrthoNet at 1-844-296-4440. 3. For assistance in completing this form, please call OrthoNet provider services toll free at 1-844-730-8503. Last Name First Name PATIENT INFORMATION: Facility or Provider Name Street Address City State ZIP If yes, ____% Pain Relief lasted ____ weeks from last (Epidural or Facet injection) performed on Date:____________ Yes No 4. Previous Epidural or Facet Injections(s)? 

Effective Date

NA

Last Reviewed

NA

Original Document

  Reference



Pain Management Prior Authorization Request Form A S P For Internal Office Use Only Fax Date: / / (including this cover page) Number of pages faxed : PROVIDER INFORMATION: Month Day Year Date of Birth / / NOTE: The information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL material. If you receive this material/information in error, please contact the sender and delete or destroy the material/information. Instructions: 1. Use this form when requesting prior authorization of Pain Management services for members of EmblemHealth.

  1. Please complete and Fax this request form along with all supporting clinical documentation to OrthoNet at 1-844-296-4440.
  2. For assistance in completing this form, please call OrthoNet provider services toll free at 1-844-730-8503. Last Name First Name PATIENT INFORMATION: Facility or Provider Name Street Address City State ZIP If yes, % Pain Relief lasted weeks from last (Epidural or Facet injection) performed on Date:____ Yes No
  3. Previous Epidural or Facet Injections(s)? Requested Facility for Surgery/Procedure(s) (If Applicable) State City Facility Tax ID Number CPT Code(s): Anticipated Date of Service(s) / / Month Day Year (Must be completed in order to process request)
  4. Please provide exact Epidural Levels or Facet Joint Levels or exact Medial Branch Nerves to be injected
    Epidural Steroid Injection Facet Joint Injection

  5. Requested Procedure(s): Trial Implant Spinal Cord Stimulator: Trial (Narcotic - Baclofen - Prialt) Implant (Narcotic - Baclofen - Prialt) Pain Pump: Facet Medial Branch

          Nerve Block:

    Local Steroid RFA Cervical Thoracic Lumbar Sacral Please Select Spinal Region(s) which applies: Left Right Bilateral Site of Injection: 1.

    Primary Diagnosis Code Copyright 2015 OrthoNet LLC Health Plan Member ID Number Telephone Number ( ) - Fax Number ( ) - Facility NPI Number Individual NPI Number National Provider Identifier (NPI) Facility Tax ID Number Individual Tax ID Number Provider Tax ID Number 63536 63536

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