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Collects member demographics and eligibility details, request type, and provider information for the requesting provider and servicing facility. Requires scheduled service date, CPT/HCPCS and diagnosis (ICD-10) codes, and submission of pertinent clinical/progress notes, including duration of problem, treatments, step-therapy attempts, physical findings, and supporting testing. 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Ongoing inpatient requests require 1 business day.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required for processing the prior authorization request?",{"text":113,"@type":109},"All fields are required unless marked optional. Requests must include pertinent clinical/progress notes and a clinical narrative, including problem duration, treatment types, step therapy attempts, relevant physical findings, and supporting test results.",{"name":115,"@type":106,"acceptedAnswer":116},"Which sections collect member, provider, and facility details?",{"text":117,"@type":109},"The form includes sections for Member Information, Requesting Provider, and Servicing Provider/Facility, covering names, contact details, identifiers, scheduled service date, procedure codes, and diagnosis codes.","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},287389,1790007929,{"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":79,"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},137451211410,"https://ap-avatar.wpscdn.com/avatar/2000bb0a9246f588df?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786362646172706240","Please allow 3 business days after submitting your request to receive a determination for outpatient services and 1 day for ongoing inpatient requests.  \nCurative Medical Prior Authorization Form  \nPHONE: 855-414-1083  \nFAX: 877-942-4448  \n[https://curative.com/priorauth](https://curative.com/priorauth)  \nAll fields are required for processing unless marked as optional. Failure to do so will cause your request to be returned unprocessed.  \n\n| Today’s Date: | Office Contact Name: |\n| --- | --- |\n| Phone: | Fax: |\n\nMember Information  \n\n| Name: |  | Phone: | DOB: | □ Male □ Female\u003Cbr>□ Other □ Unknown |\n| --- | --- | --- | --- | --- |\n| Member ID: | Request Type:\u003Cbr>□ Outpatient □ Inpatient □ Day Surg □ OT/PT/ST □ DME □ Imaging □ Home Health\u003Cbr>□ SNF □ LTAC □ Infusion □ IOP □ IP Detox □ Office Procedure □ Transplant |  |  |  |\n\nRequesting Provider  \n\n| Name: |  | Address: |  |  |\n| --- | --- | --- | --- | --- |\n| City: |  |  | State: | Zip: |\n| Phone: | Fax: | Provider NPI\\#: | Provider Federal Tax ID\\#: |  |\n\nServicing Provider/Facility  \n\n| Name of Facility & Address: |  |  |  | Scheduled Service Date: |  |\n| --- | --- | --- | --- | --- | --- |\n| City: | State: | Zip: | Provider NPI\\#: |  | Provider Federal Tax ID\\#: |\n| Description of Procedure & CPT or HCPCS(S) Codes: |  |  |  |  |  |\n| Diagnosis / ICD 10 Codes: |  |  |  |  |  |\n| *****All requests must include pertinent clinical/progress notes or provide clinical narrative, including duration of problem, types of treatment, step therapy attempts pertinent physical findings, pertinent testing results including but not limited to lab, imaging, and/or supporting specialty consultations. |  |  |  |  |  |\n\nPertinent Medical Records included: □ Yes □ No  \nCoordination of Benefits (Other Insurance)  \n\n| Other Insurance Coverage:\u003Cbr>□ Yes □ No | MVA Subrogation:\u003Cbr>□ Yes □ No | Date of Injury (optional) : | Workman’s Compensation:\u003Cbr>□ Yes □ No |\n| --- | --- | --- | --- |\n| Name of Insurance (optional) : |  | Subscriber Name & ID\\# (optional) : |  |\n\nAll medical services requested are subject to review, which includes but is not limited to, medical necessity review, determination of eligibility in accordance with the terms of the participant’s benefit plan, any deductibles, co-pays, co-insurance percentages, reasonable and customary charges, and policy maximums.  \nNOTICE OF CONFIDENTIALITY: THE INFORMATION CONTAINED IN THIS FACSIMILE (FAX) IS PRIVILEGED AND CONFIDENTIAL. IT IS INTENDED FOR THE INDIVIDUAL ENTITY INDICATED ON THIS REFERRAL FORM. YOU ARE HEREBY NOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION, COPYING, OR OTHER USE OF THIS INFORMATION BY ANYONE OTHER THAN THE RECIPIENT IS UNAUTHORIZED AND STRICTLY PROHIBITED.  \nIF YOU HAVE RECEIVED THIS FAX IN ERROR,PLEASE NOTIFY Curative Medical Management  \nMM-FOR-001 1 of 1","cbCaikEpcSsYs8GU","https://ap.wps.com/l/cbCaikEpcSsYs8GU","pdf",333490,"English","# Member Information\n# Requesting Provider\n# Servicing Provider/Facility\n## Description of Procedure & CPT or HCPCS(S) Codes\n## Diagnosis / ICD 10 Codes\n## Pertinent Medical Records included\n# Coordination of Benefits (Other Insurance)","[{\"question\":\"How long does it take to receive a determination after submitting the request?\",\"answer\":\"Outpatient requests require 3 business days for a determination. Ongoing inpatient requests require 1 business day.\"},{\"question\":\"What information is required for processing the prior authorization request?\",\"answer\":\"All fields are required unless marked optional. Requests must include pertinent clinical/progress notes and a clinical narrative, including problem duration, treatment types, step therapy attempts, relevant physical findings, and supporting test results.\"},{\"question\":\"Which sections collect member, provider, and facility details?\",\"answer\":\"The form includes sections for Member Information, Requesting Provider, and Servicing Provider/Facility, covering names, contact details, identifiers, scheduled service date, procedure codes, and diagnosis codes.\"}]","Curative Medical Prior Authorization Form - Submit Request | PDF",1789632277]