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Specifies contact channels (call for expedited; fax for standard and concurrent) and expected decision timelines based on the enrollee’s condition. Captures member details, requesting and servicing provider identifiers, primary/additional procedure codes with modifiers, admission/start and discharge dates, diagnosis codes, and inpatient service type selection. Includes requirements for required fields, supporting clinical documentation, payment disclaimer, eligibility note, and HIPAA confidentiality statement.",{"@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/inpatient-medicare-authorization-form-complete-and-submit-by-fax-or-call/283870/",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/inpatient-medicare-authorization-form-complete-and-submit-by-fax-or-call/283870.png","ImageObject",442,249,{"name":88,"@type":89},"Stanley","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-29","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How do I submit a standard (elective admission) inpatient authorization request?","Question",{"text":108,"@type":109},"Complete the form and fax it to 1-844-885-3724 for standard requests.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"When should I submit an expedited request and how is it handled?",{"text":113,"@type":109},"Submit expedited when waiting could seriously jeopardize the enrollee’s life, health, or ability to regain maximum function. Call 1-855-565-9519 for expedited requests.",{"name":115,"@type":106,"acceptedAnswer":116},"What determines the timeline for concurrent requests?",{"text":117,"@type":109},"Concurrent requests are determined within 24 hours of receipt of all necessary information.","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},283870,1790146603,{"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":20,"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},2336477405376,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","INPATIENT MEDICARE AUTHORIZATION FORM  \nExpedited Requests Call: 1-855-565-9519  \nStandard Requests Fax: 1-844-885-3724  \nConcurrent Requests Fax: 1-844-226-6443  \nFor Standard (Elective Admission) requests, complete this form and FAX to 1-844-885-3724. Determination made as expeditiously as the enrollee’s health condition requires, but no later than 14 calendar days after the receipt of request.  \nFor Expedited requests, please CALL 1-855-565-9519. 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 Concurrent requests, complete this form and FAX to 1-844-226-6443. (All inpatient stays including patients already admitted, ER patients with admit orders and direct admits) . Determination within 24 hours of receipt of all necessary information.  \n* Indicates Required Field ~~ ~~  \nDate of Birth *  \nMEMBER INFORMATION   \nMember ID * Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \nRequesting NPI * Requesting TIN * Requesting Provider Contact Name  \n*1277*  \nRequesting Provider Name Phone Fax *  \nSERVICING PROVIDER / FACILITY INFORMATION  \n Same as Requesting Provider  \nServicing NPI * Servicing TIN * Servicing Provider Contact Name  \nServicing Provider/Facility Name Phone Fax  \nAUTHORIZATION REQUEST  \nPrimary Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nStart Date OR Admission Date *  \n(MMDDYYYY)  \nDischarge Date (if applicable) otherwise  \nLength of Stay will be based on Medical Necessity  \n(MMDDYYYY)  \nDiagnosis Code *  \n(ICD-10)  \nAdditional Diagnosis Code  \n| INPATIENT SERVICE TYPE* | (Enter the Service type number in the boxes) |  | |\n| --- | --- | --- | --- |\n| 779 C-Section Delivery\u003Cbr>121 Long Term Acute Care\u003Cbr>970 Medical\u003Cbr>414 Premature/False Labor\u003Cbr>427 Rehab | 402 Skilled Nursing Facility\u003Cbr>492 Sub-Acute\u003Cbr>411 Surgical\u003Cbr>992 Transplant\u003Cbr>720 Vaginal Delivery | Behavioral Health\u003Cbr>528 BH Chemical Substance Abuse\u003Cbr>529 BH Psychiaatric Admission |  |\n\nALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.  \nCOPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.  \nDisclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policy and procedures.  \nConfidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not Rev. 11 05 2020  \nthe intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document. KM-PAF-1277","cbCaifmlDDDGDtP7","https://ap.wps.com/l/cbCaifmlDDDGDtP7","pdf",735717,"English","# Authorization request information\n## Member and provider details\n## Procedure, dates, diagnosis, and service type\n## Submission requirements and disclaimers","[{\"question\":\"How do I submit a standard (elective admission) inpatient authorization request?\",\"answer\":\"Complete the form and fax it to 1-844-885-3724 for standard requests.\"},{\"question\":\"When should I submit an expedited request and how is it handled?\",\"answer\":\"Submit expedited when waiting could seriously jeopardize the enrollee’s life, health, or ability to regain maximum function. Call 1-855-565-9519 for expedited requests.\"},{\"question\":\"What determines the timeline for concurrent requests?\",\"answer\":\"Concurrent requests are determined within 24 hours of receipt of all necessary information.\"}]","Inpatient Medicare Authorization Form - Complete and Submit by Fax or Call | PDF",1789621194]