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  • Northwood Prior Authorization Request Form For The Bmchp/well Sense Program

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 an....

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The requested clinical should be faxed to Medical Management, using the appropriate fax number for the service for which authorization is requested. Medicaid Prior Authorization Fax Numbers: Physical Health: 1-800-690-7030. Behavioral Health: 866-570-7517.

Providers may also fax prior authorization forms to El Paso Health's Pharmacy Prior Authorization at 1-855-668-8553.

Please contact TurningPoint phone at 1-855- 909-6222 or by fax at 1-603-836-8903. Dental services are not administered by NH Healthy Families. Non-participating providers must submit Prior Authorization for all services.

Prior Authorization requests will be reviewed and a decision rendered within 24 hours. 5. How does one check the status of a PA? Providers may contact Pharmacy Services at (877) 250-5227 or NH Healthy Families at (866) 769-3085.

As the Medical Home, PCPs should coordinate all healthcare services for NH Healthy Families members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization.

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© Copyright 1997-2025
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3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232