Get Fidelis Care Prior Authorization Request Form 2019-2025

This guide provides clear and supportive instructions on how to fill out the Fidelis Care Prior Authorization Request Form online. By following these steps, users can efficiently submit their requests with all necessary information included.

Follow the steps to complete the form accurately and efficiently.

1. Press the ‘Get Form’ button to access the form and open it in your document management system.
2. Fill out the Fidelis Care Member Name (last, first, middle initial) in the appropriate field.
3. Enter the Fidelis Care Member ID # along with the date of birth in the specified format (MM/DD/YYYY).
4. Provide the ICD-10 Diagnosis (Dx) Code(s) in the designated section.
5. List the CPT/Procedure Code(s) and a brief description of the services provided.
6. Indicate any applicable options, selecting the checkboxes for Medicare, Workers' Comp, or No-Fault. Include the Date of Injury and Date of Procedure if applicable.
7. Fill in the Servicing Provider Name, Phone Number, Address, Fax Number, Tax ID #, and NPI # in their respective fields.
8. If applicable, include the Provider IPA Affiliation. Then enter the Requesting Provider Name, Tax ID, and NPI.
9. Specify whether the request is for Inpatient, Outpatient/Ambulatory/23 Hour services by checking the relevant box.
10. Indicate if this request is Urgent/Emergent, Pre-service, Post-service, or Concurrent service by ticking the appropriate box. Include the authorization number if available.
11. In the Additional Information section, provide any other relevant data to support the request.
12. Check all clinical information that you are submitting along with this form, such as History & Physical, current symptoms, treatment history, lab testing, pictures, and medical records.
13. Ensure that the form is completed in its entirety for Initial and Concurrent requests. Then, fax the completed form to (800) 860-8720.
14. You will receive a notification of the service determination within the appropriate regulatory timeframe.
15. Ensure to gather and submit all additional clinical information necessary to support the request.
16. After completing the form, you can save changes, download, print, or share it as needed.

Complete your submission of the Fidelis Care Prior Authorization Request Form online today.