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To verify benefits, call: Medicare – 800-457-4708.  \nFor services scheduled in advance, submit fax to 800-  \n266-3022.  \nFor behavioral health services, submit fax to 469-913-6941  \nFor same-day appointments or urgent requests, call 800-  \n523-0023.  \nTo create a new referral or authorization online, [visit Availity.com](visit Availity.com), which is available 24/7 for your convenience.  \nContact person   Requesting provider   Phone number   Fax number   NPI or Tax ID    \n\n| Patient Details |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Humana ID Number |  | Patient First Name |  | Patient Last Name |  |\n| Date of Birth |  | ZIP Code |  |  |  |\n| Provider Details |  |  |  |  |  |\n| Treating Physician’s Name |  | Facility Name |  |  |  |\n| NPI or\u003Cbr>Tax ID |  | NPI or Tax ID |  |  |  |\n| Phone Number |  | Phone Number |  |  |  |\n| Fax Number |  | Fax Number |  |  |  |\n| Service Request |  |  |  |  |  |\n|  Update  New Request |  |  |  |  | Case No. (if any) |\n|  Inpatient | Admission date: / /  Admission type:  ER  Non-ER  SNF  Rehab  LTAC  Other Bed type:   Discharge date:  / /  Discharged to:  |  |  |  |  |\n|  Outpatient |  Evaluate and treat Observation Home health/hospice  DME rental DME purchase\u003Cbr>Diagnostic testing  Surgery  Other   First date:  / /  Last date: / / \u003Cbr>Valid for:  30 days  60 days  90 days  1 year |  |  |  |  |\n| ICD-10 Code |  |  |  |  |  |\n| Diagnosis Description |  |  |  |  |  |\n| CPT/HCPC Codes |  |  | Number of Visits/Units |  |  |\n| Description of Codes |  |  |  |  |  |\n\nThis form does not guarantee payment by Humana Inc. Responsibility for payment is subject to membership eligibility, benefit limitations and interpretation of benefits under applicable subrogation and coordination-of-benefits rules. For any other services, it will be necessary to obtain an additional authorization.  \nAttach supporting documentation (medical records, progress notes, lab reports, radiology studies, etc.) if needed. Please review guidance provided by [www.CMS.gov](www.CMS.gov) and Prior Authorization List for further information.  \nSignature   Date:  / /   \nStamp (for Humana use only)  \ni","cbCaiqvSLM6eWYBn","https://ap.wps.com/l/cbCaiqvSLM6eWYBn","pdf",157271,"English","# Contact Information\n## Requesting Provider and Phone/Fax Details\n# Patient Details\n## Humana ID and Identification\n# Provider Details\n## Treating Physician and Facility\n# Service Request\n## Inpatient and Outpatient Options\n# Diagnosis and Codes\n## ICD-10 and CPT/HCPCS\n# Submission Notes\n## Payment Responsibility and Attachments","[{\"question\":\"该表单需要填写哪些核心信息？\",\"answer\":\"需要填写请求方与提供方信息、患者基本资料、治疗场景（住院或门诊）以及服务请求细节，如诊断（ICD-10）和医疗代码（CPT/HCPCS）。\"},{\"question\":\"转介或授权的提交方式有哪些？\",\"answer\":\"可按要求拨打电话或通过传真提交；也可以在线创建新的转介或授权申请，并提供对应的全天可用入口。\"},{\"question\":\"提交该表单后是否保证Humana付款？\",\"answer\":\"不保证付款。付款责任取决于会员资格、福利限制以及对适用条款的解释；如需其他服务可能还需要额外授权，并按要求附加支持材料。\"}]","Authorization/Referral Request Form | PDF",1789623580,{"code":4,"msg":82,"data":98},[99,104,109,114,119,124,127,132,137],{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},11,"Presentations",90,"presentations",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},12,"Resumes",80,"resumes",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":111,"show_sort_weight":112,"slug":113},14,"Invoices",70,"invoices",{"id":115,"doc_module":22,"doc_module_name":25,"category_name":116,"show_sort_weight":117,"slug":118},15,"Posters",60,"posters",{"id":120,"doc_module":22,"doc_module_name":25,"category_name":121,"show_sort_weight":122,"slug":123},16,"Social Media",50,"social-media",{"id":86,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":125,"slug":126},40,"forms",{"id":128,"doc_module":22,"doc_module_name":25,"category_name":129,"show_sort_weight":130,"slug":131},18,"Letters",30,"letters",{"id":133,"doc_module":22,"doc_module_name":25,"category_name":134,"show_sort_weight":135,"slug":136},21,"Paper Templates",5,"papers-templates",{"id":138,"doc_module":22,"doc_module_name":25,"category_name":139,"show_sort_weight":4,"slug":140},158,"General","general-158"]