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Get NY State Marketplace Plans, Medicaid, Child Health Plus, And MetroPlus Gold

Prior Authorization Request Form Form Must Be Filled Out Completely and Legibly Submission of request form required for NY State Marketplace plans Medicaid Child Health Plus and MetroPlus Gold Fax 1. 212. 908. 8521 or 8522 MetroPlus Member Name Last First M. I. ICD-10 Diagnosis Dx Code s Questions 1. 800. 303. 9626 Patient / Member Information Services CPT/Procedure Code s and Description Date of Birth mm/dd/yyyy Check if applicable Workers Comp No-Fault 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 Inpatient Office Outpatient/Ambulatory/23 Hour This Request is Urgent/Emergent Facility Name and Tax ID or NPI 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 This form is to be filled out in its entirety for Initial/Concurrent requests please fax to 1. Confirmation and/or authorization do not guarantee that benefits will be paid. Payment of claims is subject to member eligibility. 212. 908. 8521 or 8522. You will be notified of the service determination within three 3 business days for initial requests and one 1 business day for concurrent requests. All requests for services require additional clinical to support the requested service s including but not limited to For continued services please fax supporting clinical information to include the number of additional visits date of last visit and progress report to 1. 212. 908. 521 or 8522. You will be notified of the medical-necessity review decision within three 3 business day. All requests for services require additional clinical to support the requested service s including but not limited to For continued services please fax supporting clinical information to include the number of additional visits date of last visit and progress report to 1. 212. 908. 521 or 8522. You will be notified of the medical-necessity review decision within three 3 business day.

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