Fillable Pre-authorization Request Form form, please conrm the patients

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Pre-authorization Request Form form, please conrm the patients

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Pre-authorization Request Form
Medical Services
Commercial, Individual, Medicare, BCBS FEP members:
Fax: 1 (855) 207-1209
Administrative Services Only (ASO) members:
Fax: 1 (844) 679-7763
Mail to: PO Box 1271, WW5-53
Portland, OR 97207-1271
Instructions: This form should be completed and lled out by the requesting provider. Prior to completing this
form, please conrm the patient’s benets, eligibility and whether pre-authorization is required.
Is this for a Medicare Preservice Benet Organization Determination Request?
Yes
No
Expedited request. I attest that this request meets the denition indicated below by checking the
expedited request box.
Fax to 1 (855) 240-6498.
Expedited is dened as: When the member or his/her provider believes that waiting for a decision within
the standard timeframe could place the member’s life, health or ability to regain maximum function in serious
jeopardy.
SECTION 1 – PATIENT INFORMATION
Patient Name (Last) First MI Patient’s Phone #
Patient’s Regence Member ID # Group # Date of Birth
SECTION 2 – PROVIDER INFORMATION
Please check one:
Requesting/Prescribing Provider
Rendering/Treating Provider
Provider Name Tax ID #
NPI # Oce Phone # Condential Voice Mail
Yes
No
Fax #
Mailing Address City State ZIP Code
Provider Specialty Email Address
Who should we contact if we require additional information?
Name Phone #
Ext.
Condential Voice Mail
Yes
No
Fax #
If a physician reviewer needs a peer to peer discussion before a determination, please provide the
treating provider’s direct phone number and availability for the next 3 to 5 days.
Phone #:
Ext:
Date:
Time:
Date:
Time:
Date:
Time:
Facility or Independent Laboratory Name Tax ID # NPI #
Mailing Address Fax #
City State ZIP Code Phone #
Ext.
Condential Voice Mail
Yes
No
FORM 5357WA - Page 1 of 2 (E. 3/19) v1
SECTION 3 – PREAUTHORIZATION REQUEST
Date of Service/Anticipated Admission __________________________
Please check one:
Outpatient Hospital
Inpatient
ASC
Office
Other __________________________
Note: This form does not serve as a notication of admission. Please reference our provider website for
instructions about how to notify us of an admission.
Please provide all diagnosis, CPT or HCPCS codes and their descriptions.
Diagnosis code(s) and description(s) CPT or HCPCS code(s) and description(s)
Primary:
Second:
Third:
SECTION 4 – DOCUMENTATION SUBMISSION
Submit the following documentation, as appropriate, with this request:
•
Specic clinical documentation as outlined in the associated Regence Medical Policy, Policy
Guidelines section
OR
• Specic clinical information documenting the applicable Medicare, or BCBS FEP medical necessity
criteria, including:
ₒ
History and physical
ₒ
Lab/Radiology/Testing results
ₒ
Current symptoms and functional impairment
ₒ
Treatment history and any other information such as chart notes that support medical
necessity for the request
Any other supporting documents you would like considered, such as letters from outpatient providers, etc.
FORM 5357WA - Page 2 of 2 (E. 3/19) v1
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Pre-authorization Request Form form, please conrm the patients

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Completed 21 December 2021

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