Must Include a 9 Or 13 Digit Authorization Number

Must include a 9 or 13 digit authorization number

APICAL HEALTH SOLUTIONS obtained from PIPA to be considered valid.

PRIOR AUTHORIZATION FORM

Procedures Requiring Authorization nay not be reimbursed Authorization Number:_______________________________ EXP:___________________________

Without authorization FAX: 708-318-2404

Requests can not be processed without documentation. Notified:__________________________________ BY:________________ DATE:______________________

CRITERIA ARE AVAILABLE UPON REQUEST BY CALLING 318-2402

Patient Information:

Name:_____________________________________________ ___ ID#_______________________________________________

D.O.B.___________________________ Phone #___________________________

Health Plan______________________________ [ ] Other Insurance: [ ] Primary [ ] Secondary / [ ] Workman’s Comp / [ ] Other______________

To be completed by the Primary Care Physician or the Requesting Provider:

Requesting Provider:________________________________ Phone:_________________________ Fax:____________________

Office Contact:_____________________________________ Alternative Phone:___________________ Fax:____________________

DX (1):___________________________ ICD-9:_________ DX (2)__________________________________ ICD-9:_____________

Date last seen by Physician for this DX:_________________ (PLEASE SEND NOTES) Patient Request?____YES ____NO

CAREFULLY DOCUMENT CODES TO FACILITATE CLAIMS PAYMENT.

Request Service / Procedure:______________________________________________ CPT CODE:___________________________

IF SURGERY REQUESTED MUST COMPLETE THE FOLLOWING: Surgical Assist Request? _____Yes _____No // _____Inpatient _____Outpatient

PHYSICIAN AUTHORIZATIONS MUST COMPLETE THE FOLLOWING: ____Consult Only ____Second Opinion Consult Only ___# Follow-up Visit

Requested Location / Physician / Provider:____________________________________________________________________________

Requesting Physician Signature:__________________________________________________ Date:___________________________

COMMENTS: History / Physical / Diagnostic workup to be attached. Homebound Status and skilled need required for HHC requests.

INFORMATION BELOW TO BE COMPLETED BY APICAL HEALTH SOLUTIONS STAFF

Date / Time Requested-Received / Initials:_____________________________ PCP:_________________________________ POD#:________________

Covered Benefit: [ ] Yes [ ] No COB?: [ ] Yes [ ] No [ ] Unknown

Eligibility Confirmed (Type / Effective Date):__________________________ Eligibility Confirmed by / Date:________________________________________

Nurse Review Decision:____________________________________________ Nurse Initials / Review Date:___________________________________________

Documentation Requested / Initial Review:_____________________________ Documentation Received:_____________________________________________

Medical Director Review Decision: [ ] Approved Request [ ] Propose Denial [ ] Withdrawal

Reasons for Proposed Denial Decisions:

[ ] Non-covered Benefit [ ] Physicians office requests withdrawal

[ ] OOA/OON / Non-par

[ ] Not enough documentation received to approve request

[ ] Medical information does not meet specific criteria

CRITERIA:_________________________________________ RATIONALE:________________________________________

____________________________________________________ _____________________________________________________

ALTERNATIVE RECOMMENDATIONS:_______________________________________________________________________________________________________

Medical Director Signature:_______________________________________________________________________ Date:__________________________________

Pre-Key into database by (initials):____________________________________ Determination Entered:________________ To HP (PD ONLY):______________

STAT’S are for emergencies, not for scheduling issues. MAIL CLAIMS TO: PO BOX 95638, Las Vegas, NV 89193-5638

Authorization is subject to Eligibility and Benefits. Authorization is not a guarantee of payment. Effective: 2/1/2000/REV6/2001/REV 6/2003

Requests can not be processed without documentation. Codes are required.