Get Fidelis Care Prior Authorization Request Form 2018-2025

Navigating the Fidelis Care Prior Authorization Request Form is an essential process for securing necessary medical services. This guide provides clear, step-by-step instructions to help users effectively complete the form online, ensuring all required information is accurately provided.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. In the 'Member Information' section, input the Fidelis Care member name in the format of last name, first name, and middle initial. Enter the member's ID number and date of birth in the specified format.
3. For the 'Services' section, include the relevant ICD-10 diagnosis code(s) followed by the CPT/procedure code(s) along with a brief description of the procedure.
4. If applicable, check the relevant boxes for Medicare, Workers' Compensation, or No-Fault, and provide the date of injury and date of procedure as needed.
5. Fill in the 'Provider Information' section with the provider's name, phone number, address, fax number, tax ID number, and NPI number.
6. Indicate the provider's IPA affiliation if necessary and specify if the request is for inpatient, outpatient, or ambulatory services by checking the relevant box.
7. Determine the nature of the request by checking the appropriate type: Urgent/Emergent, Pre-service, Post-service, or Concurrent service.
8. Complete the 'Additional Information' section by providing the facility's tax ID or NPI number.
9. Attach any required clinical information needed to support this request, checking all applicable items in the list provided.
10. Review all entered information for accuracy and completeness before finalizing.
11. Once completed, save changes to the form. You can download or print the form, or share it as necessary.

Begin filling out your Fidelis Care Prior Authorization Request Form online today!