Get Residential Treatment Authorization Request Form - Wellcare

Filling out the Residential Treatment Authorization Request Form is a vital process for ensuring that individuals receive the appropriate care they need. This guide provides a clear and comprehensive approach to completing the form online, making it accessible for everyone, regardless of their experience with such documentation.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the Residential Treatment Authorization Request Form and open it in the editor.
2. Select the appropriate request type, either 'Standard Request' or 'Expedited Request'. If you choose 'Expedited Request', ensure you certify that the standard review timeframe may seriously jeopardize the member's health.
3. Provide member information: fill in the last name, first name, middle initial, date of birth, WellCare ID number, gender, and if applicable, details about third-party insurance.
4. Enter ordering physician/practitioner information, including their name, WellCare ID number, NPI number, specialty, and contact details.
5. Fill in treating provider/practitioner details, similar to the previous step, ensuring that NPI numbers and addresses are accurate.
6. Input facility information by providing the name, address, contact number, facility ID, and NPI number.
7. Complete the diagnosis section by entering primary ICD-9 code(s) and any additional codes that apply, along with the expected discharge date.
8. Provide a detailed narrative of the presenting problem and patient symptomology, including the onset date and duration of symptoms.
9. Document the initial plan of care (IPOC) including details on therapy sessions, treatment interventions, and signatures where required.
10. Confirm any alternative placements explored, detailing successes or challenges to provide context for the request.
11. For continued stay reviews, summarize current symptoms and behaviors to support the need for ongoing residential care, including any changes to medications.
12. Once all sections are completed, review the form for accuracy, save any changes, and proceed to download, print, or share the completed document as necessary.

Start filling out your Residential Treatment Authorization Request Form online today.