Prior Authorization Request Form Form

Prior Authorization Request Form Required for: Metal-Level Products, Managed Medicaid, CHP, and Medicare Advantage Fax: (800) 860-8720 Questions: (888) 343-3547 Member Information Fidelis Care Member Name (Last, First, M.I.): Fidelis Care Member ID #: Date of Birth: / / Services ICD-10 Diagnosis (Dx) Code(s): CPT/Procedure Code(s) and Description: Check if applicable: [ ] Medicare [ ] Workers' Comp [ ] No-Fault Date of Injury: / / Date of Procedure (if applicable): / / Servicing Provider Name: Servicing Provider Phone #: ( )

• Servicing Provider Tax ID #: Servicing Provider Address: Servicing Provider Fax #: ( )
• Servicing Provider NPI #: Provider IPA Affiliation (if applicable): Requesting Provider Name: Requesting Provider Tax ID / NPI: Check if applicable: [ ] Inpatient [ ] Outpatient/Ambulatory/23 Hour Facility Name: Facility Tax ID#: This Request is: [ ] Urgent/Emergent [ ] Pre-service [ ] Post-service [ ] Concurrent service Auth #:____ Additional Information: Please submit the following clinical information with this form as appropriate for this request (check all included): [ ] History & Physical [ ] Current Symptoms and Functional Impairment [ ] Treatment history [ ] Lab/Radiology testing results [ ] Pictures [ ] Medical record (chart notes)  This form is to be filled out in its entirety for Initial and Concurrent requests; please fax to 1-800-860-8720.  You will be notified of the service determination within the appropriate regulatory timeframe.  All requests for services require additional clinical to support the requested service(s) including but not limited to: History & Physical, previous diagnostic tests, and consultation reports, Prescription from prescribing physician.  Confirmation and/or authorization do not guarantee that benefits will be paid. Payment of claims is subject to member eligibility. Rev. 5.22.2019 Facility NPI #: