Get Centene Enterprise Authorization Fax Form - Illinicare

Filling out the Centene Enterprise Authorization Fax Form - Illinicare can be a straightforward process when you understand each section and its requirements. This guide will provide you with step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the authorization fax form.

1. Press the ‘Get Form’ button to obtain the authorization fax form. Open the form in your preferred editor.
2. Fill in the date of birth for the member in the designated field formatted as MMDDYYYY.
3. Enter the member ID or Medicaid ID, ensuring that you complete all required fields marked with an asterisk (*).
4. Select whether your request is a standard or urgent request. If it's urgent, ensure the requesting physician's signature is included.
5. Provide the requesting provider information, including the requesting NPI, TIN, contact name, and phone and fax numbers.
6. If applicable, indicate if the servicing provider or facility information is the same as the requesting provider. If not, fill in the servicing provider’s NPI, TIN, name, phone, and fax.
7. Input the authorization request ICD-9 and CPT/HCPCS codes as necessary. Include the primary procedure and any additional procedure codes.
8. Fill in the start date or admission date, and provide the discharge date if applicable, both formatted as MMDDYYYY.
9. Choose the service type from the list provided, entering the corresponding service type number in the boxes.
10. Ensure all required fields are completed. Incomplete forms will be rejected.
11. Attach copies of all supporting clinical information. Submit your form once all required information is filled out and verified.
12. Save the completed form, and then choose to download, print, or share it as needed.

Complete the Centene Enterprise Authorization Fax Form - Illinicare online today to ensure a smooth authorization process.