Get Prior Authorization Form - Coventry Health Care Of Illinois
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How to fill out the Prior Authorization Form - Coventry Health Care Of Illinois online
This guide provides clear and detailed instructions for completing the Prior Authorization Form for Coventry Health Care Of Illinois online. Following these steps will help ensure that your request is submitted correctly and efficiently.
Follow the steps to fill out the form accurately.
- Click the ‘Get Form’ button to obtain the form and open it for completion.
- In the first section, fill in the patient name, date of birth (D.O.B.), and member ID. This information is crucial for identifying the individual for whom the authorization is requested.
- Provide the name and fax number of the primary care provider (PCP) and the ordering physician. Accurate details here will facilitate communication regarding the authorization.
- Enter the diagnosis along with the corresponding ICD9 code. This information is necessary for medical necessity reviews.
- List the service requested and the relevant CPT code. These codes are vital for processing the authorization efficiently.
- Include any additional comments or clinical information that may support the medical necessity of the request.
- For outpatient authorization requests, input details for the provider to whom the referral is made, including the full name, phone number, fax number, and address.
- Specify whether this is a new referral or a follow-up, along with anticipated dates of service and the number of visits requested.
- If requesting an admission or procedure, include the facility name and city, admission date, procedure or service, and the associated procedure code.
- Indicate whether the request is for office, outpatient, or inpatient service, and provide the date of the request along with the physician or provider's signature.
- Complete the 'Staff Only' section if applicable, marking any relevant plan types, insurances, and limitations.
- Finally, ensure that all information is accurate and complete before saving changes, downloading, printing, or sharing the form.
Complete your authorization requests online to ensure a smooth and efficient process.
In the merger, First Health will merge with and into Coventry Merger Sub Inc., which is a Delaware corporation and wholly owned subsidiary of Coventry. Merger Sub will continue after the merger as the surviving entity and a wholly owned subsidiary of Coventry.
Fill Prior Authorization Form - Coventry Health Care Of Illinois
For healthcare providers who need to complete the Coventry Prior Authorization form, click the button below to begin the process. Get Form Now Download PDF. Prior authorization alone is not a guarantee of benefits or payment. For efficiency and easier tracking, submit your Medical Prior Authorization request through the CountyCare Provider Portal. Click here to login and learn more.
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