43-3547 Member Informa ti on Fidelis Care Member ID #: Date of Birth: / / Services ICD-10 Diagnosis (Dx) Code(s ): CPT/Procedure Code(s) and Description: Check if applicable: Medicare Workers' Comp No-Fault Date of Injury: / / Date of Procedure (if applicable): / / Servicing Provider Name: Servicing Provider Phone #: ( Servicing Provider Address: Servicing Provider Fax #: ( ) ) - Servicing Provider Tax ID #: Servicing Provider NPI #: Provider IPA Affiliation (if app.
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How to fill out the Fidelis Care Prior Authorization Request Form online
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.
- Press the ‘Get Form’ button to access the form and open it in your document management system.
- Fill out the Fidelis Care Member Name (last, first, middle initial) in the appropriate field.
- Enter the Fidelis Care Member ID # along with the date of birth in the specified format (MM/DD/YYYY).
- Provide the ICD-10 Diagnosis (Dx) Code(s) in the designated section.
- List the CPT/Procedure Code(s) and a brief description of the services provided.
- 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.
- Fill in the Servicing Provider Name, Phone Number, Address, Fax Number, Tax ID #, and NPI # in their respective fields.
- If applicable, include the Provider IPA Affiliation. Then enter the Requesting Provider Name, Tax ID, and NPI.
- Specify whether the request is for Inpatient, Outpatient/Ambulatory/23 Hour services by checking the relevant box.
- 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.
- In the Additional Information section, provide any other relevant data to support the request.
- 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.
- Ensure that the form is completed in its entirety for Initial and Concurrent requests. Then, fax the completed form to (800) 860-8720.
- You will receive a notification of the service determination within the appropriate regulatory timeframe.
- Ensure to gather and submit all additional clinical information necessary to support the request.
- 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.
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How to check prior authorization status on Fidelis?
Navigate to Providers. Under Provider Resources, find Authorization Grids. Click on the Medicaid, Child Health Plus, HealthierLife (HARP), Medicare, Essential Plan or Qualified Health Plan drop-down menu. Select Authorization Lookup Tool at the top of the menu.
How to get a prior authorization from Fidelis?
To get started: All Prior Authorizations can be submitted online, except the following: Must be submitted via the appropriate fax line or by phone at 1-888-FIDELIS (1-888-343-3547): Urgent Requests.
What is a prior authorization request form?
Prior authorization — also frequently referred to as preauthorization — is a utilization management practice used by health insurance companies that requires certain procedures, tests and medications prescribed by healthcare clinicians to first be evaluated to assess the medical necessity and cost-of-care ramifications ...
How can I get prior authorization faster?
How To Speed Up The Prior Authorization Process: Important Tips and Reminders Provide correct and complete patient information. ... Keep a master list of procedures that require authorizations. ... Document causes of Prior Authorization rejection. ... Subscribe to payor newsletters. ... Follow evolving industry requirements.
What is needed for a prior authorization?
As part of the prior authorization process, the ordering provider must certify that the information supporting the medical necessity claim is true and accurate. This may include the need to substantiate why a more expensive treatment is necessary when a lesser cost alternative is available.
Why is it so hard to get a prior authorization?
Errors and mistakes occurring in the benefits and eligibility processes can result in prior auth denial as well. If patient demographic and insurance information is incorrect, outdated, or missing, or the wrong paperwork is used, slowdowns in the prior auth process can occur.
How do I complete a prior authorization?
Pharmacy providers and prescribers can submit a PA request via fax number 1-800-869-4325 by utilizing the preferred Medi-Cal Rx Prior Authorization Request Form or any of the following approved forms: 50-1, 50-2, 61-211.
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