Fillable Prior Authorization Request Form

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Prior Authorization Request Form

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  • 41 other fields

Country of origin: OTHERS
File type: PDF

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Prior Authorization Request Form
• Please refer to the Procedure Code Lookup Tool on the website https://forms.chpw.org/pclt for all the services that require prior authorization.
• With your submitted form, please attach supporting clinical documentation.
• Incomplete forms and requests without clinical information will delay processing
• A Prior Authorization is not a guarantee of payment; Payment is subject to member eligibility and benefts at the time of service.
For Apple Health/Medicaid:
Fax: (206) 652-7078
Notification is required by
next business day
Please call Customer Service
to verify eligibility & benefits:
1-800-440-1561;
Monday through Friday, 8 a.m.-5 p.m.
Updated: 03/21
For Medicare Advantage Plans:
Fax: (206) 652-7065
Notification is required
within 24 hours
Please call Customer Service
to verify eligibility & benefits:
1-800-942-0247;
7 days a week, 8 a.m. - 8 p.m.
CASCADE SELECTAPPLE HEALTH (MEDICAID) MEDICARE ADVANTAGE
For expedited processing for both Apple Health/Medicaid, Medicare Advantage Plans and CHNW-Cascade Select please submit
Prior Authorization requests via the Care Management Portal at https://jiva.chpw.org/cms/ProviderPortal
Alternately, you can fax Prior Authorization requests to the appropriate number below:
For Cascade Select:
Fax: (206) 652-7075
Notification is required
within 24 hours
Please call Customer Service
to verify eligibility & benefits:
1-866-907-1906;
Monday through Friday, 8 a.m.-5 p.m.
ORDERING PROVIDER INFORMATION
First Name: Last Name: Contact Fax#:
Contact Person at this oce:
Ordering provider is Specialist
Specialty:
PATIENT INFORMATION
First Name: Last Name: MI: Date of Birth:
Member ID:
Patient Retro Enrolled with CHPW
Retro Enrolled Date:
SERVICE PROVIDED BY
First Name: Last Name: Address:
Participating
Non-Participating
Tax ID:
NPI:
Specialty: Contact Phone #: Contact Fax #:
Facility Name: Address:
Participating
Non-Participating
Tax ID:
NPI:
Specialty Contact Phone #: Contact Fax #:
Inpatient
Diagnosis: Date of Service:
Services being requested:
New request
Extension
Contact Phone:
Ordering provider is PCP
PCP’s Clinic Name:
Primary: Code (
) Description:
Secondary: Code ( ) Description:
CPT /HCPCS #1 Description:
CPT /HCPCS #2 Description:
CPT /HCPCS #3 Description:
Outpatient
Routine
Urgent
Please indicate CLINICAL urgency of request
Request*
#Visits:
Duration:
*Last Date of service if an extension
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Prior Authorization Request Form

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Completed 18 March 2022

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