Get St Pt Or Ot Treatment Request Form Fidelis
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How to fill out the St Pt Or Ot Treatment Request Form Fidelis online
Filling out the St Pt Or Ot Treatment Request Form is an essential step for users seeking services through Fidelis Care. This guide provides comprehensive instructions to help you successfully complete the form online, ensuring that all necessary information is accurately submitted.
Follow the steps to effectively complete the treatment request form
- Click the ‘Get Form’ button to access the treatment request form. This will allow you to open the document in an online editor for easy completion.
- Begin by entering the member's name and Fidelis member ID number in the designated fields. Ensure that the name matches what is on file to avoid any processing delays.
- Provide the date of birth for the individual requiring treatment. This information helps in verifying eligibility for services.
- Select the type of services requested: Speech Therapy (SP), Physical Therapy (PT), or Occupational Therapy (OT) and fill in the corresponding ICD-10 diagnosis code(s) that relate to the treatment request.
- Enter any applicable CPT/procedure code(s) along with indicating if the person is a Medicare beneficiary or involved in worker's compensation or no-fault incident.
- Fill in the name, phone number, and tax ID or NPI number of the referring provider, along with the date of the initial and last visit pertaining to treatment.
- Indicate the number of visits requested along with the frequency of those visits, documented clearly to avoid confusion.
- Document any previous treatment details, including dates and progress, specifically regarding ambulation, transfers, pain control, activities of daily living, and whether a home program is in place.
- Complete the therapist's information including name, facility name, provider ID, phone, address, and fax number for streamlined communication.
- Review all entered information for accuracy. Ensure that each required field is completed as incomplete or illegible forms will delay processing.
- Finally, save any changes made to the document. You may also download, print, or share the completed form as needed for your records or to submit.
Take action now and fill out the St Pt Or Ot Treatment Request Form Fidelis online to ensure your treatment needs are promptly addressed.
Related links form
Effective October 1, 2019, physical medicine services (physical therapy, occupational therapy and speech therapy) will require Prior Authorization for all services provided to all Fidelis Care members except for those in the Medicare Advantage (MA), Medicaid Advantage Plus (MAP), and Dual Advantage (DUAL) products.
Fill St Pt Or Ot Treatment Request Form Fidelis
Requests after the first 90-day period must provide a new prescription as evidence that the referring provider has been informed of progress to date. Prior Authorization Request Form (PDF). Psychological Testing Request Form (PDF). Requirements: Clinical information and supportive documentation should consist of current physician order, notes and recent diagnostics. However, providers may call Provider Services at 1- to inquire on prior authorization requests not received within 15 days. This request typically includes details about the proposed treatment, the medical necessity for the service, and relevant patient information. 2. Physical, Occupational, or Speech Therapist for Fidelis Care members.
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