Fillable Prior Authorization Request Form Aetna Better Health of (Aetna Better Health)

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Prior Authorization Request Form Aetna Better Health of (Aetna Better Health)

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Revised 7/1/2020
AetnaBetterHealth.com/Illinois-Medicaid
IL-20-07-03
Aetna Better Health
®
of Illinois
3200 Highland Ave, MC F648
Downers Grove, IL 60515
Aetna Better Health® of Illinois
Prior Authorization Request Form
Phone: 1-866-329-4701/Fax: 1-877-779-5234
For urgent outpatient service requests (required within 72 hours) call us.
Date of Request:
MEMBER INFORMATION
Name: ID Number
Date of Birth: PCP Name:
Other Insurance ? / Policy Holder / Policy Number:
Gender (circle one): F M
PROVIDER INFORMATION
Ordering/Requesting Provider:
Name:
NPI (Required*)
Address:
Telephone #:
Fax #:
Contact Person:
AUTHORIZATION INFORMATION
Diagnosis/ICD-10 Code(s) (Required*)
Servicing Provider/Facility/Specialist:
Name:
NPI (Required*)
Address:
Telephone #:
Fax #:
Specialty:
1. 2. 3. 4. 5.
Service/Procedure requested (CPT or HCPCS codes Required*):
1.
2.
3.
4.
5.
6.
7.
8.
9.
Type of Procedure/Level of care (circle one): Inpatient Outpatient In Office
Date(s) of service: Number of visits/units:
REQUIRED DOCUMENTATION
Include supporting pertinent clinical information (Required*) ---5 pages or less--- (e.g clinical/progress notes, lab/imaging
reports, plan of care, letter of medical necessity, etc).
*NOTE: FAILURE TO INCLUDE NPI NUMBERS, DIAGNOSIS, CPT/HCPCS CODES AND SUPPORTING CLINICAL INFORMATION WILL
RESULT IN THE RETURN OF THIS FORM UNPROCESSED.
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Prior Authorization Request Form Aetna Better Health of (Aetna Better Health)

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Completed 11 March 2022

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