Fillable Rationale for Out-of-Network Care

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Rationale for Out-of-Network Care

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File type: PDF

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Request Date:
Submitted By:
Phone:
Fax:
For items and services, please allow 72 hours for processing urgent requests and 14 days for non-urgent requests. For Part B drugs, please
allow 24 hours for processing urgent requests and 72 hours for non-urgent requests.
Rationale for Out-of-Network Care
____________________________________________________________________________________________________
______________________________________________________________________________________________________________
MEMBER INFORMATION
Member Name:
Plan Member ID:
Date of Birth:
Phone:
REQUESTING PROVIDER INFORMATION
Name:
Address:
Fax:
NPI#:
SERVICING PROVIDER INFORMATION
Same as Requesting Provider
In-Network
Out-of-Network
Name:
Address:
Fax:
NPI#:
In-Network
Out-of-Network
Place of Treatment:
Provider Office
Outpatient
Facility
Inpatient Facility
Home
Other
Location/Facility Name:
Location/Facility Address:
Fax:
NPI#:
Attestation for Non-Participating Providers (*Required Field): This authorization serves as a one-time out of network agreement at 100% of
Medicare allowable for a non-participating provider. This authorization request will be valid for 30 days.
Signature: ____________________________________________________ Date: __________________________________
SERVICE REQUEST
Behavioral Services - IOP
Consult/Office Visit
Home Health
Surgery - Inpatient
Behavioral Services - PHP
Diagnostics Imaging
Infusion Therapy/Injections
Surgery - Outpatient
Card./Pulm. Rehab
Dialysis
Orthotics & Prosthetics
Transplant - Evaluation
Chemotherapy
DME
PT/ST/OT (after eval, circle
all that applies)
Other (describe)
Other Relevant Information:
ICD 10 Code(s):
CPT/HCPCS Codes with Quantity for Each Code:
Begin Date:
End Date:
Please see Prior Authorization List for the services that require prior authorization. For the complete list, please visit us online at
www.ccaillinois.com/medicare for CCAI members, www.eonhp.com for Eon members, and www.clearspringhealthcare.com for Clear Spring Health
members. Disclaimer: Member must be eligible at the time services are provided. Services must be a covered Health Plan Benefit and medically
necessary with prior authorization. An authorization is not a guarantee of payment. Y1045_UM F36-121420_C
Pre-Service Authorization Form
URGENT REQUEST – I certify that this request is urgent and medically necessary to treat an illness, injury or condition
(not life threatening) within 72 hours to avoid complications and unnecessary suffering or severe pain.
This authorization is valid for 90 days, unless otherwise indicated. Only authorized services may be provided. Clinical
documentation is required for authorization processing, please attach all documents. Fax documents: 866-613-0157.
For questions, call: 877-364-4566.
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Rationale for Out-of-Network Care

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Completed 28 October 2021

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