[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283872-105":53,"doc-detail-283872-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","allwell-outpatient-medicare-authorization-form-508","Allwell Outpatient Medicare Authorization Form - 508","","Allwell outpatient Medicare prior authorization request form for additional units/visits/days. Covers standard, expedited, and Part B drug requests with specific fax or call instructions, and includes required member, requesting provider, and servicing provider/facility details. Request sections capture procedure codes (CPT/HCPCS with modifiers), diagnosis code (ICD-10), start and end/admission and discharge dates, and total units. Requires all marked fields and supporting clinical information; incomplete forms are rejected and authorization does not guarantee payment.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/allwell-outpatient-medicare-authorization-form-508/283872/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/allwell-outpatient-medicare-authorization-form-508/283872.png","ImageObject",442,249,{"name":88,"@type":89},"Pentious","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-29","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",20,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"How do I submit a standard outpatient authorization request?","Question",{"text":109,"@type":110},"Complete the form and fax it to 1-844-330-7158. Determinations are made as quickly as the enrollee’s condition requires, but no later than 14 calendar days after receipt.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"When should an expedited request be used, and how is it submitted?",{"text":114,"@type":110},"Use expedited when waiting under the standard timeframe could jeopardize the enrollee’s life, health, or ability to regain maximum function. Call 1-844-786-7711 for expedited requests.",{"name":116,"@type":107,"acceptedAnswer":117},"What information is required to complete the authorization request?",{"text":118,"@type":110},"All required fields must be completed, including member information, requesting and servicing provider/facility details, primary and additional procedure codes with modifiers, start and end/admission and discharge dates, diagnosis code (ICD-10), and total units/visits/days. 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Existing Authorization  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nUnits  \nStandard Requests: Fax to 1-844-330-7158  \nPart B Drug request: Fax to 1-844-941-1327  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\nFor Standard requests, complete this form and FAX to 1-844-330-7158. Determination made as expeditiously as the enrollee’s health condition requires, but no later than 14 calendar days after receipt of request.  \nFor Expedited requests, please CALL 1-844-786-7711. Expedited requests are made when the enrollee or his/her physician believes that waiting for a decision under the standard timeframe could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.  \nFor Part B Drug request please fax 1-844-941-1327.  \n* INDICATES REQUIRED FIELD    \nDate of Birth*  \nMEMBER INFORMATION  \n\n|  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\nMember ID* Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \n*1175*  \n*  \nRequesting NPI  \n\n|  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nRequesting Provider Name  \n*  \nRequesting TIN  \n\n|  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nPhone  \nRequesting Provider Contact Name  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nFax*  \nSERVICING PROVIDER / FACILITY INFORMATION  \nSame as Requesting Provider  \nServicing NPI*  \n\n|  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nServicing Provider/Facility Name  \nServicing TIN*  \n\n|  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nPhone  \nServicing Provider Contact Name  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nFax  \nAUTHORIZATION REQUEST  \n*  \nPrimary Procedure Code  \n(CPT/HCPCS) (Modifer)  \nAdditional Procedure Code  \n\n|  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n\n\n|  |  |\n| --- | --- |\n\n(CPT/HCPCS) (Modifer)  \nAdditional Procedure Code  \n\n|  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n\n\n|  |  |\n| --- | --- |\n\n(CPT/HCPCS) (Modifer)  \nAdditional Procedure Code  \n\n|  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n\n\n|  |  |\n| --- | --- |\n\n(CPT/HCPCS) (Modifer)  \n*  \nStart Date OR Admission Date  \n\n|  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n(MMDDYYYY)  \nEnd Date OR Discharge Date  \n\n|  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n(MMDDYYYY)  \nDiagnosis Code*  \n\n|  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n\n(ICD-10)  \nTotal Units/Visits/Days  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n\n| OUTPATIENT SERVICE TYPE* (Enter the Service type number in the boxes) |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| 712 Cochlear Implants & Surgery\u003Cbr>299 Drug Testing\u003Cbr>922 Experimental Investigational Services\u003Cbr>205 Genetic Testing and Counseling\u003Cbr>249 Home Health\u003Cbr>290 HyperbaricOxygenTherapy\u003Cbr>395 Infertiity Diagnosis-Treatment\u003Cbr>729 Neuropsychological Testing\u003Cbr>410 Observation\u003Cbr>790 Occupational Therapy\u003Cbr>997 Office Visit/Consult | 794 Outpatient Services\u003Cbr>171 Outpatient Surgery\u003Cbr>202 Pain Management\u003Cbr>101 Physical Therapy\u003Cbr>650 Radiation Therapy\u003Cbr>201 Sleep Study\u003Cbr>701 Speech Therapy\u003Cbr>212 Therapy Evaluation\u003Cbr>993 Transplant Evaluation\u003Cbr>209 Transplant Surgery\u003Cbr>724 Transportation | BEHAVIORAL HEALTH SERVICE TYPE\u003Cbr>510 BH Medical Management\u003Cbr>530 BH PHP\u003Cbr>512 BH Community Based Services\u003Cbr>513 BH Crisis Psychotherapy\u003Cbr>514 BH Day Treatment\u003Cbr>515 BH Electroconvulsive Therapy\u003Cbr>518 BH Mental Health /Chemical\u003Cbr>519 BH Outpatient Therapy\u003Cbr>520 BH Professi","cbCaimBLu17ge4QS","https://ap.wps.com/l/cbCaimBLu17ge4QS","pdf",502600,"English","# Authorization Request Details\n## Request Type and Submission\n## Member and Provider Information\n## Procedure, Diagnosis, and Dates\n## Service Type and Required Fields","[{\"question\":\"How do I submit a standard outpatient authorization request?\",\"answer\":\"Complete the form and fax it to 1-844-330-7158. Determinations are made as quickly as the enrollee’s condition requires, but no later than 14 calendar days after receipt.\"},{\"question\":\"When should an expedited request be used, and how is it submitted?\",\"answer\":\"Use expedited when waiting under the standard timeframe could jeopardize the enrollee’s life, health, or ability to regain maximum function. Call 1-844-786-7711 for expedited requests.\"},{\"question\":\"What information is required to complete the authorization request?\",\"answer\":\"All required fields must be completed, including member information, requesting and servicing provider/facility details, primary and additional procedure codes with modifiers, start and end/admission and discharge dates, diagnosis code (ICD-10), and total units/visits/days. Supporting clinical information copies are required as well.\"}]","Allwell Outpatient Medicare Authorization Form - 508 | PDF",1789621195]