[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-286835-105":53,"doc-detail-286835-en":126},{"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":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","carelon-preauthorization-and-rqi-request-fax-form","Carelon - Preauthorization and RQI Request Fax Form","","This document provides the official Carelon Medical Benefits Management Preauthorization and RQI (Radiology Quality Initiative) Request Fax Form. It is designed for healthcare providers to request medical procedure authorizations by submitting patient, subscriber, referring physician, and service facility information. The form requires comprehensive clinical details, including patient diagnosis, symptoms, previous treatments, relevant diagnostic testing results, and specific protocol indicators such as injury or cancer-related screenings. It ensures that all necessary information is captured to facilitate efficient processing of medical benefit authorizations by the Carelon department. Incomplete submissions are explicitly noted to be returned to the sender, highlighting the importance of thorough documentation.",{"@graph":63,"@context":118},[64,80,101],{"@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/carelon-preauthorization-and-rqi-request-fax-form/286835/",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/carelon-preauthorization-and-rqi-request-fax-form/286835.png","ImageObject",442,249,{"name":88,"@type":89},"Đào","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-27","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What should I do if my preauthorization request is urgent?","Question",{"text":108,"@type":109},"If the request is urgent, please call Carelon directly rather than relying solely on the fax submission.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information must be included in the Clinical Information section?",{"text":113,"@type":109},"You must provide the patient's diagnosis or symptoms with duration and intensity, suspected medical conditions, previous treatments, results of relevant prior testing, and details regarding injury or cancer protocol relevance.",{"name":115,"@type":106,"acceptedAnswer":116},"What happens if the submitted form is incomplete?",{"text":117,"@type":109},"Incomplete forms will be returned to the sender, so it is critical to complete all information requested on the form before submission.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},286835,1790242025,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},1374402968488,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","PREAUTHORIZATION/ RQI REQUEST  \nFAX FORM  \nInstructions: If Urgent request please call CARELON  \nPlease complete ALL information requested on this form, incomplete forms will be returned to sender.  \nTO: CARELON MEDICAL BENEFITS MANAGEMENT PREAUTH/RQI DEPARTMENT  \n[www.carelon.com](www.carelon.com)  \nFAX \\#: 800-610-0050  \n| ubscriber (Insurance Holder) and Patient Informatio |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Subscriber Name:\u003Cbr>Last: First: |  |  | Patient Name:\u003Cbr>Last : First: |  |\n| ID \\#: (include alpha prefix) |  |  |  DOB:  /  / SEX: M  F RELATIONSHIP TO SUBSCRIBER: SELF SPOUSE CHILD | |\n| SSN: |  |  |  |  |\n| Health Plan Name: |  |  |  |  |\n| Group \\#: Product type: PPO POS HMO |  |  |  |  |\n| Other: |  |  |  |  |\n| Referring Physician Information The physician who is ordering the exam |  |  | Provider Information\u003Cbr>Where the service will be provided |  |\n| Name:\u003Cbr>Last: First: |  |  | Name of\u003Cbr>Facility: |  |\n| Phone: (  ) |  |  | Address: |  |\n| Fax: (  ) |  |  | Phone: (  ) |  |\n| Address: |  |  |  |  |\n| Specialty: |  |  | |  |\n|  |  |  |  |  |\n| rocedure(s) Information (please include CPT Code, if available |  |  |  |  |\n| Date of Procedure: /  / Procedure: CPT Code: |  |  |  |  |\n| Date of Procedure: / / Procedure: CPT Code: |  |  |  |  |\n| Date of Procedure: | /________/ | Procedure: CPT Code: |  |  |\n|  |  |  |  |  |\n\nClinical Information (all info must be completed)  \n1. Patient’s diagnosis or symptoms (include duration, frequency, and intensity)    \n2. What is the physician suspecting or ruling out with the requested study?  \n3. Has the patient received treatment for the above symptoms (include duration and type)?  \n4. List any previous relevant testing (i.e. labs, diagnostic imaging, or other test), include results:  \n5. Is this injury related? Yes   No Date and type of Injury:  \n6. Is study part of a standard post-chemo/radiation protocol in a patient with a prior cancer diagnosis? Yes No Cancer type:","cbCaibxcSPMU6uoM","https://ap.wps.com/l/cbCaibxcSPMU6uoM","pdf",128586,"English","# Subscriber and Patient Information\n# Referring Physician and Provider Information\n# Procedure Information\n# Clinical Information Requirements","[{\"question\":\"What should I do if my preauthorization request is urgent?\",\"answer\":\"If the request is urgent, please call Carelon directly rather than relying solely on the fax submission.\"},{\"question\":\"What information must be included in the Clinical Information section?\",\"answer\":\"You must provide the patient's diagnosis or symptoms with duration and intensity, suspected medical conditions, previous treatments, results of relevant prior testing, and details regarding injury or cancer protocol relevance.\"},{\"question\":\"What happens if the submitted form is incomplete?\",\"answer\":\"Incomplete forms will be returned to the sender, so it is critical to complete all information requested on the form before submission.\"}]","Carelon - Preauthorization and RQI Request Fax Form | PDF",1789631599]