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Get Northwood Prior Authorization Request Form For The BMCHP/Well Sense Program

Requests for authorizations requested outside the timeframes will result in an Administrative Denial. If you do not receive a response to your fax request within 2 business days please call Northwood at 1-866-802-6471. Northwood Prior Authorization Request Form for the BMCHP/Well Sense Program Telephone 1-866-802-6471 Fax 1-877-552-6551 Date Of Request Provider Name/City/State Contact Person BMCHP ID Last Name Patient Phone Ordering Physician Name Other Insurance Name Date of Service HCPCS Code DMEPOS Provider Information NW Provider ID Phone Patient/Member Information Date of Birth First Name Patient Height Fax Equipment/Medical Supply Information Diagnosis Code Modifier ICD-9/10 NU/RR/BO/BA RT/LT Quantity Utilization Management Section Have you attached the medical documentation necessary to review this request YES NO i.e. requests for over-quantity should have valid prescription and LOMN attached requests for Enteral nutrition should have valid prescription height weight BMI LOMN and growth charts infants. Is this an urgent/emergent request Was this dispensed from a loan closet or stock and bill Manufacturer cost invoices must be submitted for NOC/IC codes. If this is an NOC/IC code request have you attached your manufacturer cost invoice Important Note Section To document medical necessity for the item/service requested above the written diagnosis and supporting clinical information must be attached and included with your request and be signed by a qualified practitioner PCP treating Physician/ARNP. All durable medical equipment prosthetics orthotics and medical supply DMEPOS services require a preauthorization* If any DMEPOS service is provided without a preauthorization the claim will be denied* Authorizations are performed Monday thru Friday 8 30 a*m* to 5 00 p*m* Urgent/emergent requests for services performed afterhours or on weekends need to be requested within the next two 2 scheduled business days. Is this an urgent/emergent request Was this dispensed from a loan closet or stock and bill Manufacturer cost invoices must be submitted for NOC/IC codes. If this is an NOC/IC code request have you attached your manufacturer cost invoice Important Note Section To document medical necessity for the item/service requested above the written diagnosis and supporting clinical information must be attached and included with your request and be signed by a qualified practitioner PCP treating Physician/ARNP. If this is an NOC/IC code request have you attached your manufacturer cost invoice Important Note Section To document medical necessity for the item/service requested above the written diagnosis and supporting clinical information must be attached and included with your request and be signed by a qualified practitioner PCP treating Physician/ARNP. All durable medical equipment prosthetics orthotics and medical supply DMEPOS services require a preauthorization* If any DMEPOS service is provided without a preauthorization the claim will be denied* Authorizations are performed Monday thru Friday 8 30 a*m* to 5 00 p*m* Urgent/emergent requests for services performed afterhours or on weekends need to be requested within the next two 2 scheduled business days.

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