Prior Authorization Request Form Form Must Be Filled Out Completely And Legibly Submission of request form required for NYS of Health Managed Medicaid CHP FHP and Medicare Advantage Fax 800 860-8720 Fidelis Care Member Name Last First M. I. Questions 888 343-3547 Patient / Member Information Services CPT/Procedure Code s and Description ICD- 10 Diagnosis Dx Code s Date of Birth mm/dd/yyyy Check if applicable Medicare No-Fault Workers Comp Date of Injury mm/dd/yyyy Date of Procedure if applicable mm/dd/yyyy Provider Name Phone Tax ID or NPI Include area codes Fax IPA Affiliation if applicable Inpatient Facility Name and Tax ID or NPI Outpatient/Ambulatory/23 Hour This Request is Urgent/Emergent Additional Information Pre-service Please Submit the following clinical information with this form as appropriate for this request circle all included History Physical Current Symptoms and Functional Impairment Treatment history Lab/Radiology testing results Pictures Medical record chart notes Th....
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How to fill out the 800 860 8720 online
This guide provides clear and supportive instructions on completing the 800 860 8720 form online. By following these steps, you can efficiently fill out the required information for your authorization request.
Follow the steps to successfully complete the form.
- Click the ‘Get Form’ button to access the form and open it within your document management system.
- Begin by entering the Fidelis Care member's name in the format of last name, first name, and middle initial.
- Fill in the Fidelis Care member ID number in the designated field.
- Provide the CPT/procedure code(s) along with a brief description of the services needed.
- Enter the ICD-10 diagnosis code(s) relevant to the request.
- Record the date of birth of the patient in the mm/dd/yyyy format.
- If applicable, check the appropriate boxes for Medicare, No-Fault, or Workers' Compensation.
- If there's a date of injury, enter it in mm/dd/yyyy format; if there is a date of procedure, do so as well.
- Complete the provider's name and include their phone number with area code.
- Input the provider's tax ID or NPI number and fax number.
- If applicable, specify the IPA affiliation.
- Indicate whether the request is for inpatient or outpatient services.
- Check the appropriate option if the request is urgent/emergent or for pre-service.
- Add any additional information that might support the request.
- Circle all included clinical information that you are submitting with the form, such as history and physical, treatment history, or lab results.
- Review the entire form to ensure all fields are filled out completely and legibly before submission.
- Submit the completed form by faxing it to 800-860-8720. You will receive a determination within the regulatory timeframe.
Complete your documents online to ensure swift processing of your request.
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Get answers to your most pressing questions about US Legal Forms API.
Is Fidelis a Medicare plan?
Fidelis Care offers new Medicare Advantage plans in 2022. Dual Advantage plans are also available for people who qualify for both Medicare and Medicaid coverage.
What is the purpose of a prior authorization?
Prior authorization (also called “preauthorization” and “precertification”) refers to a requirement by health plans for patients to obtain approval of a health care service or medication before the care is provided. This allows the plan to evaluate whether care is medically necessary and otherwise covered.
What is the new name for Fidelis Care?
Starting in 2022, our Medicare Advantage and Dual Advantage plans have a new name: Wellcare By Fidelis Care.
Who provides Medicaid in New York?
Local Department of Social Services. Your Local Department of Social Services (LDSS) may be able to assist you in obtaining your health insurance coverage and/or provide you with information about other programs and benefits you may qualify.
What is the claims address for Fidelis Care NY?
Requests for administrative review must be sent to the following address: Attn: Claims Reconsideration, Fidelis Care, 480 CrossPoint Parkway, Getzville, NY 14068.
Is Fidelis Care Catholic?
Fidelis Care is the business name for the New York State Catholic Health Plan, Inc., a nonprofit 501(c)(3) managed care organization for members who receive health insurance from Medicaid, Child Health Plus, Family Health Plus, Family Health Plus Employer Buy-in, and some categories of Medicare.
Is Fidelis Care New York Medicaid?
Fidelis Care, a leading health insurer that serves all of New York State, offers free or low-cost comprehensive health coverage, including Medicaid Managed Care, Medicare Advantage, Child Health Plus, and plans available through NY State of Health, The Official Health Plan Marketplace.
Where is Fidelis Care accepted NYC?
Your insurance is accepted at the following Gotham Health Centers/Clinics: NYC Health + Hospitals/Gotham Health, Belvis. NYC Health + Hospitals/Gotham Health, Cumberland. NYC Health + Hospitals/Gotham Health, East New York.
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