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Get Kentucky Prior Authorization Form

Prior Authorization Request Form Phone 888-725-4969 Fax to 855-454-5579 A determination notice will be faxed to the requesting provider. CoventryCares of Kentucky responds to prior authorization requests within two working days. Requests received after 7 00 p.m. ET are processed the next business day. Prior Authorization Request Form Phone 888-725-4969 Fax to 855-454-5579 A determination notice will be faxed to the requesting provider. CoventryCares of Kentucky responds to prior authorization requests within two working days. Requests received after 7 00 p*m* ET are processed the next business day. Incomplete requests will delay the prior authorization process. Please include pertinent chart notes to expedite this request. TYPE OF REQUEST URGENT for urgent medical need only - response within 24 hours NON-URGENT for routine services response within 2 business days INPATIENT OUTPATIENT HOME HEALTH CARE of receiving all clinical information PATIENT INFORMATION Patient Name Last First I. D. Other Insurance Name of Carrier YES NO MI Gender M F Job Related MVA YES NO FROM- REQUESTING PROVIDER Date of Birth / EPSDT special service request Is the member currently pregnant Requesting Provider Please Print Tax ID Contact Person in Requesting Provider s Telephone Fax Office Clinical Contact Person Name of PCP Phone TO- WHERE WILL PATIENT RECEIVE SERVICES Address Telephone Physician/Provider/Facility Requested Where services will be rendered provide name of facility if other than provider office or patient s home KY Medicaid Provider Today s Date Tentative Date of Service/Admission Were member school based services interrupted Start Date End Date CLINICAL INFORMATION ICD-9 Description ICD-9 Codes required CPT/HCPCS Codes required CPT/HCPCS Description Comments List Days/Visits/Units being requested DME must have Rx attached* CLINICAL INDICATIONS/RATIONALE FOR REQUEST To expedite a determination on your request for services please attach clinical documentation/medical records to support your request. Please include the following Conservative treatment tried and failed Applicable Diagnostic testing with results and lab values Medications KYCM00218 Revised 07/2013. CoventryCares of Kentucky responds to prior authorization requests within two working days. Requests received after 7 00 p*m* ET are processed the next business day. Incomplete requests will delay the prior authorization process. Please include pertinent chart notes to expedite this request. Incomplete requests will delay the prior authorization process. Please include pertinent chart notes to expedite this request. TYPE OF REQUEST URGENT for urgent medical need only - response within 24 hours NON-URGENT for routine services response within 2 business days INPATIENT OUTPATIENT HOME HEALTH CARE of receiving all clinical information PATIENT INFORMATION Patient Name Last First I. TYPE OF REQUEST URGENT for urgent medical need only - response within 24 hours NON-URGENT for routine services response within 2 business days INPATIENT OUTPATIENT HOME HEALTH CARE of receiving all clinical information PATIENT INFORMATION Patient Name Last First I. D. Other Insurance Name of Carrier YES NO MI Gender M F Job Related MVA YES NO FROM- REQUESTING PROVIDER Date of Birth / EPSDT special service request Is the member currently pregnant Requesting Provider Please Print Tax ID Contact Person in Requesting Provider s Telephone Fax Office Clinical Contact Person Name of PCP Phone TO- WHERE WILL PATIENT RECEIVE SERVICES Address Telephone Physician/Provider/Facility Requested Where services will be rendered provide name of facility if other than provider office or patient s home KY Medicaid Provider Today s Date Tentative Date of Service/Admission Were member school based services interrupted Start Date End Date CLINICAL INFORMATION ICD-9 Description ICD-9 Codes required CPT/HCPCS Codes required CPT/HCPCS Description Comments List Days/Visits/Units being requested DME must have Rx attached* CLINICAL INDICATIONS/RATIONALE FOR REQUEST To expedite a determination on your request for services please attach clinical documentation/medical records to support your request..

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