Fillable Request for Preauthorization of Benefits for Ancillary Service

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Request for Preauthorization of Benefits for Ancillary Service

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The Request for Preauthorization of Benefits for Ancillary Service form is 2 pages long and contains:

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Country of origin: OTHERS
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Member’s Name:
Member’s ID #: DOB:
Home Phone: Alternate Phone:
Primary Diagnosis: ICD9:
Secondary Diagnosis: ICD9:
Height: Weight: (Provide if necessary to service member — selecting size, dose, etc.)
YOUR INFORMATION
Provider’s Name: Location:
Tax ID Number: NPI:
Contact’s Name: Phone: Fax:
PHYSICIAN INFORMATION
Physician’s Name: NPI:
Phone: Fax: UPIN:
Request for Preauthorization of Benefits for Ancillary Service
Please refer to our website, BlueChoiceSC.com, for a complete list of ancillary services that require authorization.
Fax this form to BlueChoice HealthPlan, Health Care Services
Fax: 800-610-5685 or 803-714-6463
(Rev. 12/10)
M Original (Prospective) Request M Reauthorization (Concurrent) Request
MEMBER INFORMATION
The attached information is condential and is intended only for the use of the addressee identied above. If the reader of this message is not the
intended recipient(s), please be advised that any dissemination, distribution or copying of the communication is strictly prohibited. Anyone who receives
this communication in error should notify us immediately by telephone (1-800-327-3183). The document can be faxed to us at (1-800-610-5685). After
contacting us, the original document can be destroyed or returned to us via U.S. mail by sending to the following address: BlueChoice HealthPlan,
Mail Code AX-325, P.O. Box 5170, Columbia, SC 29260-6170.
(Continued on back.)
TYPE OF SERVICE REQUESTED
M DME M Home Health M Prosthetics
SERVICES REQUESTED
Billing Code Description Quantity Pricing Dates of Service
(HCPCS, CPT) (Days or Units) (From – To)
M Rental M Purchase
(Rev. 12/10)
The attached information is condential and is intended only for the use of the addressee identied above. If the reader of this message is not the
intended recipient(s), please be advised that any dissemination, distribution or copying of the communication is strictly prohibited. Anyone who receives
this communication in error should notify us immediately by telephone (1-800-327-3183). The document can be faxed to us at (1-800-610-5685). After
contacting us, the original document can be destroyed or returned to us via U.S. mail by sending to the following address: BlueChoice HealthPlan,
Mail Code AX-325, P.O. Box 5170, Columbia, SC 29260-6170.
Member’s Name: ID #:
NOTE: 1) Miscellaneous, NOS, custom and non-contracted codes/services must be accompanied by an invoice showing U&C charge and
description of services/products to be rendered to member. 2) All drug requests must include a complete physician’s prescription. 3) All
special medical devices requests must include clinical records and information explaining medical necessity. 4) Re-authorization request
for home health services must include Plan of Care and most recent nursing and/or therapy notes.
Please attach pertinent clinical documentation and indicate the number of pages you are faxing to us,
including cover page. Thanks! _______ Pages
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Request for Preauthorization of Benefits for Ancillary Service

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Completed 22 June 2022

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