Prior Authorization Attachment Form
Cover Sheet
1.
Provider Number
or NPI/ZIP/ZIP+4:
2. Member ID Number:
3. Prior Authorization Number:
Note: Do not place another Fax Cover Sheet on top.
Three fields below are required and must match the prior authorization request.
Purpose:
This form is to be used when a prior authorization request (PAR) requiring a paper attachment is being submitted.
Submission of the completed forms along with the required attachments will allow the appropriate review process to
be conducted by the OHCA.
This fax contains confidential information and is intended only for the individual named. If you are not the named addressee you should not disseminate, distribute
or copy this fax. Please notify the sender immediately by phone if you have received this e-fax by mistake and destroy the fax you received. Fax transmission
cannot be guaranteed to be secure or error-free as information could be intercepted, corrupted, lost, destroyed, arrive late or incomplete. The sender therefore
does not accept liability for any errors or omissions in the contents of this message, which arise as a result of fax transmission.
Instructions:
1. Box 1; fill in the Servicing Provider Number.
2. Box 2; fill in the nine-digit member identification number.
3. Box 3; write “new” to initiate a new prior-authorization request. A “new” PAR is also
required for continuation of previously authorized services. PAR dates must not overlap
previously approved dates of service.
a. For SoonerCare or Insure Oklahoma online PAR submissions, enter the corresponding PAR
number in box 3.
b. To submit additional documentation or to amend a PAR, enter the existing PAR number
in box 3 to assure your documentation will be linked with the correct existing PAR.
4. The Initial Request box is to be checked when requesting “new” services.
5. The Amended box is to be checked when minor changes are required to an existing approved authorization.
Also, enter the prior authorization number in box 3 above so your amendment request will be linked with
the correct existing PAR.
6. The Additional Documentation box is
to be checked when submitting additional documentation to be added
to an existing PAR. Enter the PAR number in box 3 above so your documentation will be linked with the
correct existing PAR.
7. The Photos/Videos Included box is to be checked when submitting photos or videos for review. Mail
to: HP Attn: Prior Authorizations, 2401 NW 23rd, Suite 11, Oklahoma City, OK. 73107
8. Fax all forms and documentation to: 405-702-9080 Toll Free 1-866-574-4991
Note: Do not place another Fax Cover Sheet on top.
This form is for use with Prior Authorization requests requiring attachments.
Initial Request
Amended
Additional Documentation
Photos/Videos Included
OHCA Revised 05/8/2014 HCA-13A
Sender’s Name: Phone Number:
12345319599/74146/74146-6936
