Get 061904 Pro Na Caid 2013 Home Health Services Prior Auth Form

Filling out the 061904 PRO NA CAID 2013 Home Health Services Prior Auth Form online can seem daunting, but this guide will walk you through each section clearly and succinctly. With straightforward instructions, you will be able to complete the form accurately to request prior authorization for home health services.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Choose the appropriate request type by selecting either 'Initial Request' or 'Continuation of Services'.
3. Fill in the member information section. Provide the WellCare ID, last name, first name, middle initial, Medicaid/Medicare number, phone number, and date of birth.
4. Complete the ordering provider information. Enter the WellCare ID number, NPI number, name of the provider, street address, city, state, zip code, phone number, fax number, and provider type/specialty.
5. Provide the treating provider/vendor information. Specify the place of service by checking the appropriate box and include the treating provider’s details: WellCare ID, NPI number, name, address, phone, and fax numbers.
6. In the requested services section, fill in the requested dates of service by entering the 'From' and 'To' dates. If this is a continuation of services, mention the previous authorization number.
7. Indicate the number of visits rendered to date and select the discipline requested while entering the quantity of visits needed in the appropriate fields.
8. Fill in the required ICD-9 codes and CPT/HCPC codes as applicable and provide descriptions for each condition or service requested.
9. Review all the entered information for accuracy and completeness. Make any necessary changes.
10. Save your changes, and proceed to download, print, or share the form as needed.

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